YOU
SPOUSE
Name
Address
City, State, Zip
Home Phone
Cell Phone
Email
DOB
Marital Status
Citizenship
US citizenNaturalized citizenResident alien
SSN
Occupation
Occupation Status
RetiredEmployed
Military Status
NoneActiveVeteran
Dates of Service:
Children
NoYes
How Many:
JointMineStepAdoptedFoster
Grandchildren
Primary contact (if other than client): Relationship:
Phone: Do they have Power of Attorney for you? YesNo
Referred by: Name: Company:
Financial AdvisorAccountantFamily/FriendWebsiteWorkshop/ClassOther
Financial Advisor: Firm: Phone:
Accountant: Firm: Phone:
EXISTING ESTATE PLAN
DATE EXECUTED
Will
YesNo
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? YesNo
If yes, indicate the dates and amounts:
You: Current health status: GoodConcernProblem
Specific concern/problem:
Spouse: Current health status: GoodConcernProblem
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?
List your CHILDREN (if applicable) or BENEFICIARIES (use additional sheets if needed)
Name: MaleFemale Date of Birth:
Address: Phone:
Child of: jointyouspouseadoptedfoster child Other relation:
studentemployed - Occupation:
SingleMarried 1st2ndother - how long? Spouse’s name: Occupation:
Children: none How many? Ages:
Special needs/considerations:
Potential problems/hardships/issues:
MONTHLY INCOME: ** It is very important you indicate in each category ownership and dollar amount separately, as well as total value.**
SOURCE
JOINT
TOTAL
Wages
$
Pension
Social Security
Investments
Other
Total Value
TYPE OF ASSET
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. $
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
Real estate: residence (per tax bill)
Real estate: other
Vehicles: automobile, motorcycle, boats, snowmobiles, etc.
TYPE
Mortgage
Loans Payable
Amount Withheld from Social Security for Medicare
Cost of Medicare Supplement
Farm
Partnership or LLC Interest
Corporation
Other:
Notes/Comments: