Intake Form


    Your Information

    YOU

    SPOUSE

    Name

    Address

    City, State, Zip

    Home Phone

    Cell Phone

    Email

    DOB

    Marital Status

    DOD
    DOD

    Citizenship

    SSN

    Occupation

    Occupation Status

    Military Status

    Dates of Service:

    Dates of Service:

    Children

    How Many:

    How Many:

    Grandchildren

    How Many:

    How Many:

    Primary contact (if other than client): Relationship:

    Phone: Do they have Power of Attorney for you?

    Referred by: Name: Company:

    Financial Advisor: Firm: Phone:

    Accountant: Firm: Phone:

    Your Estate Planning

    EXISTING ESTATE PLAN

    YOU

    SPOUSE

    DATE EXECUTED

    Will

    Trust

    Power of Attorney

    Health Care Proxy

    Living Will

    Long-Term Care Insurance

    Funeral & Burial Plans

    Rank the following (1-8) in order of importance for you currently (1 = Most Important / 8 = Least Important)

    Avoid probate

    Protect assets from government, lawsuits & nursing homes

    Keep estate matters private

    Protect assets for family from predators after my death (i.e., my spouse’s disability or remarriage, my children’s beneficiary’s lawsuits, divorce or bankruptcy)

    Minimize/eliminate taxes

    Remain independent and in control of my care and/or assets

    Keep it simple for my family when something happens to me (disability or death)

    Provide detailed instructions and authority to people I trust to have the care I desire provided for me if I become disabled

    What would completing your estate planning accomplish for you?

    What do you see as your biggest risk if you don’t complete your estate plan?

    VA/Medicaid applicants only:

    Have you transferred or gifted any funds over the last 5 years?

    If yes, indicate the dates and amounts:

    Your Health

    You: Current health status:

    Specific concern/problem:

    Spouse: Current health status:

    Specific concern/problem:

    Do you or your spouse require long term care now?

    If receiving care currently, please indicate the facility and date of admission:

    Have you or your spouse ever been in a hospital or rehab facility for thirty days or more?

    Your Family

    List your CHILDREN (if applicable) or BENEFICIARIES (use additional sheets if needed)

    Name: Date of Birth:

    Address: Phone:

    Child of: Other relation:

    - Occupation:

    - how long? Spouse’s name: Occupation:

    Children: How many? Ages:

    Special needs/considerations:

    Potential problems/hardships/issues:

    Name: Date of Birth:

    Address: Phone:

    Child of: Other relation:

    - Occupation:

    - how long? Spouse’s name: Occupation:

    Children: How many? Ages:

    Special needs/considerations:

    Potential problems/hardships/issues:

    Name: Date of Birth:

    Address: Phone:

    Child of: Other relation:

    - Occupation:

    - how long? Spouse’s name: Occupation:

    Children: How many? Ages:

    Special needs/considerations:

    Potential problems/hardships/issues:

    Name: Date of Birth:

    Address: Phone:

    Child of: Other relation:

    - Occupation:

    - how long? Spouse’s name: Occupation:

    Children: How many? Ages:

    Special needs/considerations:

    Potential problems/hardships/issues:

    Name: Date of Birth:

    Address: Phone:

    Child of: Other relation:

    - Occupation:

    - how long? Spouse’s name: Occupation:

    Children: How many? Ages:

    Special needs/considerations:

    Potential problems/hardships/issues:

    Name: Date of Birth:

    Address: Phone:

    Child of: Other relation:

    - Occupation:

    - how long? Spouse’s name: Occupation:

    Children: How many? Ages:

    Special needs/considerations:

    Potential problems/hardships/issues:

    Name: Date of Birth:

    Address: Phone:

    Child of: Other relation:

    - Occupation:

    - how long? Spouse’s name: Occupation:

    Children: How many? Ages:

    Special needs/considerations:

    Potential problems/hardships/issues:

    Name: Date of Birth:

    Address: Phone:

    Child of: Other relation:

    - Occupation:

    - how long? Spouse’s name: Occupation:

    Children: How many? Ages:

    Special needs/considerations:

    Potential problems/hardships/issues:

    Your Finances

    MONTHLY INCOME: ** It is very important you indicate in each category ownership and dollar amount separately, as well as total value.**

    SOURCE

    YOU

    SPOUSE

    JOINT

    TOTAL

    Wages

    $

    $

    $

    $

    Pension

    $

    $

    $

    $

    Social Security

    $

    $

    $

    $

    Investments

    $

    $

    $

    $

    Other

    $

    $

    $

    $

    Total Value

    $

    $

    $

    $

    TYPE OF ASSET

    YOU

    SPOUSE

    JOINT

    TOTAL

    Cash, Checking, Savings, CDs, Money Market & Cash Management Accounts

    $

    $

    $

    $

    Investment/Broker-held Accounts (not including cash) and Mutual Fund Accounts

    $

    $

    $

    $

    Retirement Accounts: IRA, 401K, 403B, SEP, etc.

    $

    $

    $

    $

    Life Insurance: death benefit and cash value

    D.B. $

    C.V. $

    D.B. $

    C.V. $

    D.B. $

    C.V. $

    D.B. $

    C.V. $

    Stocks you hold outside of brokerage accounts

    $

    $

    $

    $

    Bonds you hold outside of brokerage accounts

    $

    $

    $

    $

    Annuities: $ = original amount invested date=month/year purchased CV=current value

    $ date

    CV

    $ date

    CV

    $ date

    CV

    $ date

    CV

    Real estate: residence (per tax bill)

    $

    $

    $

    $

    Real estate: other

    $

    $

    $

    $

    Vehicles: automobile, motorcycle, boats, snowmobiles, etc.

    $

    $

    $

    $

    Total Value

    $

    $

    $

    $

    OTHER ASSETS NOT LISTED:

    TYPE

    YOU

    SPOUSE

    JOINT

    TOTAL

    $

    $

    $

    $

    $

    $

    $

    $

    Total Value

    $

    $

    $

    $

    LIABILITIES:

    TYPE

    YOU

    SPOUSE

    JOINT

    TOTAL

    Mortgage

    $

    $

    $

    $

    Loans Payable

    $

    $

    $

    $

    Amount Withheld from Social Security for Medicare

    $

    $

    $

    $

    Cost of Medicare Supplement

    $

    $

    $

    $

    Other

    $

    $

    $

    $

    Total Value

    $

    $

    $

    $

    BUSINESS INTERESTS:

    TYPE

    YOU

    SPOUSE

    JOINT

    TOTAL

    Farm

    $

    $

    $

    $

    Partnership or LLC Interest

    $

    $

    $

    $

    Corporation

    $

    $

    $

    $

    Other:

    $

    $

    $

    $

    Total Value

    $

    $

    $

    $

    Notes/Comments: