Date: _________________
CLIENT'S INFORMATION
Legal Name:
_________________________________________________
Other names ever known by:
_____________________________________
Address:
_____________________________________________________
E-mail Address: _____________________
Telephone: (__) ____________________
Facsimile: (__) _____________________
Social Security Number: ___-__-____
Driver's License ______________
Birth date and Age:
D/o/b: __/__/__
Age: ___
Place of Birth:
City: ___________________
State or Country: _________
State of Residence ___________
Military Service Record
_________________________________________
College/University Record
_________________________________________
Marital Status ___________
Citizenship: _________
Immigration Status: _____________________________
Occupation (and Title or Position):
______________________________________
Employer:
__________________________________________________________
Business Address:
____________________________________________________
Business Telephone ____________________________
Major Health Problems
________________________________________________
CLIENT'S PREVIOUS MARRIAGES
1) Name of spouse: ______________
Currently alive? Y __ N __
Current City and State of Residence: __________________, __
How did Marriage Terminate? Death ___ Divorce ___ Annulment
___
Date of Termination: __/__/____
Title of Divorce or Probate Court: _____________________
Any other relevant information regarding this marriage?
__________________________________________________________
2) Name of spouse: ______________
Currently alive? Y __ N __
Current City and State of Residence: __________________, __
How did Marriage Terminate? Death ___ Divorce ___ Annulment
___
Date of Termination: __/__/____
Title of Divorce or Probate Court: _____________________
Any other relevant information regarding this marriage?
__________________________________________________________
CLIENT'S CHILDREN FROM PRIOR RELATIONSHIPS
1) Name: ______________
Name of Other Parent: _____________________
Birthdate: __/__/____
If Deceased: Date of Death: __/__/____
Age at death: ___
If Alive: Current Address: _____________________
City and State: ______________________________
Age: ___
Name of Spouse: ______________ None __
SSN: ___-__-____
2) Name: ______________
Name of Other Parent: _____________________
Birthdate: __/__/____
If Deceased: Date of Death: __/__/____
Age at death: ___
If Alive: Current Address: _____________________
City and State: ______________________________
Age: ___
Name of Spouse: ______________ None __
SSN: ___-__-____
3) Name: ______________
Name of Other Parent: _____________________
Birthdate: __/__/____
If Deceased: Date of Death: __/__/____
Age at death: ___
If Alive: Current Address: _____________________
City and State: ______________________________
Age: ___
Name of Spouse: ______________ None __
SSN: ___-__-____
If any children are disabled, list public benefits currently
received: _______________________
If any children are stepchildren or foster children, are they
to be treated as children under your
testamentary plan? ____________
CLIENT'S EXISTING DOCUMENTS
__ Will
Date of Will/Trust: __/__/____
Wills--Location of original: __________
Wills--List all codicils by date: ______________
__ Revocable Living Trust
__ Power of Attorney for Health Care
Date power granted: __/__/____
Date power expires: __/__/____
__ Power of Attorney for Property
Date power granted: __/__/____
Date power expires: __/__/____
__ Power of Attorney for (Other) _____________
Date power granted: __/__/____
Date power expires: __/__/____
ASSETS / LIABILITIES
Real Estate
1) Address: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
2) Address: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
3) Address: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
Household Furniture, Furnishings, Appliances
1) Description: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
2) Description: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
3) Description: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
Jewelry, Antiques, Art, Coin Collections, Fur Coats, Oriental
Rugs, Etc.
1) Description: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
2) Description: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
3) Description: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
4) Description: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
Vehicles, Boats, Trailers
1) Description: ________________________Year_____
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
2) Description: ________________________Year_____
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
3) Description: ________________________Year______
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
4) Description: ________________________Year_____
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
Bank Accounts
1) Bank: ________________________
Account#______________________
Fair Market Value: $_____________
2) Bank: ________________________
Acct.#________________________
Fair Market Value: $_____________
3) Bank: ________________________
Acct# ________________________
Fair Market Value: $_____________
Cash: $______________
Life Insurance
Account/Type: ________________________Policy#__________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
Beneficiary: _______________________
Account/Type ________________________Policy#__________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
Beneficiary: _______________________
Equipment, Machinery, Livestock
1) Description: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
2) Description: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
3) Description: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
Stocks, Bonds, Secured Notes
1) Description: ________________________Acct.#__________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
2) Description: ________________________Acct.#__________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
3) Description: ________________________Acct.#_________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
4) Description: ________________________Acct.#__________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
Retirement, Pension, Profit-Sharing, Annuities,
Military/Veteran's Benefits
1) Description: ________________________Acct.#__________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
2) Description: ________________________Acct.#__________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
3) Description: ________________________Acct.#__________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
Accounts Receivable, Unsecured Notes, Tax Refunds
1) Description: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
2) Description: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
3) Description: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
4) Description: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
Partnerships, Other Business Interests
1) Description: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
2) Description: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
3) Description: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
4) Description: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
Other Assets and Liabilities (alimony, rental income, existing
trust funds, credit card
balances, pending lawsuits, judgments, etc.)
1) Description: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
2) Description: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
3) Description: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
4) Description: ________________________
Gross Fair Market Value: $_____________
Amount of Debt: $____________
Net Fair Market Value: $_____________
Safe Deposit Box:
Name of Bank: ____________
Address: _______________
Box No.: __________
Who has access? ______________
Location of key(s): __________________
Are there any assets outside the United States? Yes __ No
__
Describe: ___________________________________________
Is Client anticipating receiving any substantial gifts or
inheritances in the near future?
___________________________________________________________________
___________________________________________________________________
FIDUCIARY AGENTS AND ADVISORS
Initial Executor(s): (The Executor follows your Will)
Name: _____________
Address: ______________________
Telephone No.: (___) ___-____
Fax No.: (___) ___-____
Successor Executor(s):
Name: _____________
Address: ______________________
Telephone No.: (___) ___-____
Fax No.: (___) ___-____
Initial Trustee(s): (The Trustee follows the Trust, the
first Trustee will be you)
Name: _____________
Address: ______________________
Telephone No.: (___) ___-____
Fax No.: (___) ___-____
Successor Trustee(s):
Name: _____________
Address: ______________________
Telephone No.: (___) ___-____
Fax No.: (___) ___-____
Initial Agent under Advance Health Care Directive:
Name: _____________
Address: ______________________
Telephone No.: (___) ___-____
Fax No.: (___) ___-____
Successor Agent Under Advance Health Care Directive:
Name: _____________
Address: ______________________
Telephone No.: (___) ___-____
Fax No.: (___) ___-____
Initial Agent Under Power of Attorney for Finances:
Name: _____________
Address: ______________________
Telephone No.: (___) ___-____
Fax No.: (___) ___-____
Successor Agent Under Power of Attorney for Finances:
Name: _____________
Address: ______________________
Telephone No.: (___) ___-____
Fax No.: (___) ___-____
Initial Guardian(s) for minor children:
Name: _____________
Address: ______________________
Telephone No.: (___) ___-____
Fax No.: (___) ___-____
Successor Guardian(s) for minor children:
Name: _____________
Address: ______________________
Telephone No.: (___) ___-____
Fax No.: (___) ___-____
Is any beneficiary to be specifically disinherited? ___ Yes ___
No
If yes, who? ____________________________
