ESTATE PLANNING PERSONAL DATA SHEET

(SINGLE)

 

 

Date                                            Tel. Home                                        Tel. Bus.                                      

This form is extremely important.  Your accuracy and completeness in responding will help me best represent you.  Bring this information with you to the appointment.  Please list names as they would appear on legal documents.

 

 

PERSONAL DATA

 

Full Name                                                                                                                              

                        (print name as shown on your checks)       

 

Address                                                                                                                                  

 

                                                                                                                Zip                        

 

Birth Date                                                     Social Security Number                                          

 

U.S. Citizen? Yes                     No                    Annual Income                                                  

 

If widowed, please list date of death of spouse________________________________________________

 

 

REFERRAL

 

By whom were you referred to this office?

 

Name                                                                                                                                     

 

Address                                                                                                                                  

 

 

DISPOSITIVE INTENTIONS

 

1.  For whom do you want to provide in your Will?

 

                                                                                                                                               

 

                                                                                                                                                

 

2.         If you have children, do you wish to treat all of your children equally? 

            Yes                   No                 

            After your death, at what age do you want distribution to your children:

            (e.g. a typical plan provides for 1/3 at age 25, 1/3 at age 30 and 1/3 at age 35)

 

            Your choice of age:                                                                                                       

 

3.         If you have grandchildren, do you wish to leave a specific amount of money or a percentage of

            your estate to your grandchildren?       Yes                   No                 

 

            If so, how much and to whom?                                                                                         

 

            Your choice of age:                                                                                                       

 

4.  Do you want to leave a specific amount of money or other assets to any charity?

            Yes                  No                             

 

            If so, how much?                                                                                                           

 

            Name and Address of Charity:                                                                                         

 

                                                                                                                                               

 

5.         Is there any family member that you want to specifically exclude from receiving anything under

            your Will?   Yes                               No                             

 

            If so, whom?                                                                                                                

 

 

EXECUTOR

 

Who do you wish to serve as your Executor?

 

First Choice                                                                                                                            

 

Second Choice                                                                                                                         

 

 

TRUSTEE

 

Who do you want to serve as your Trustee?

 

First Choice                                                                                                                            

 

Second Choice                                                                                                                         

 

GUARDIAN

 

If you have minor children, who do you want to act as Guardian?

 

First Choice                                                                                                                            

 

Second Choice                                                                                                                         

 

 

LIVING WILL

 

Do you want your Living Will to provide for withdrawal of artificial food and fluid? 

Yes                             No                           

 

Do you want to donate your eyes or organs?  Yes                          No                          

 

Do you want your health care representative to consult with any other person prior to acting? 

Yes                         No                           

 

Name of proposed Health Care Agent (usually family member or friend)                                         

 

                                                                                                                                             

 

Address of proposed Health Care Agent                                                                                      

 

                                                                                                                Zip                        

 

Name of proposed Alternate Health Care Agent                                                                           

 

Address of proposed Alternate Health Care Agent                                                                        

 

                                                                                                                Zip                         

What is the name, address and telephone number of your primary care physician?

 

                                                                                                                                            

 

                                                                                                                                             

 

 

POWER OF ATTORNEY

 

Name of proposed Financial Agent (usually family member or friend)                                             

 

                                                                                                                                             

 

Address of proposed Financial Agent                                                                                         

 

                                                                                                                  Zip                      

 

Name of proposed Alternate Financial Agent                                                                               

 

Address of proposed Alternate Financial Agent                                                                            

 

                                                                                                                   Zip                     

 

 

MISCELLANEOUS

 

Do you have any other legal issues which I should be aware of?  Yes                 No            

 

If yes, please explain:                                                                                                               

 

 

CHILDREN (if applicable)

CHILD'S NAME	ADDRESS WITH ZIP CODE	DATE OF     BIRTH

 

GRANDCHILDREN (if applicable)

GRANDCHILD'S NAME	ADDRESS WITH ZIP CODE	DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

w-data.sgl

rev. 7/29/98

CLIENT ASSET INFORMATION

INTAKE FORM

SINGLE

Name of Client:                                                                                                                                

 

FINANCIAL SUMMARY

                                                                                                           

                                                                                       ASSETS                             LIABILITIES

 

Bank Accounts                                                                                   $____________                                  $____________

 

Real Estate (residence)                                                                     $____________                                  $____________

 

Real Estate (other)                                                                             $____________                                  $____________

                                               

Savings Certificates (CD's)                                                             $____________                                  $____________

               

Stocks - Non Mutual Funds (Not Held by Broker)                  $____________                                  $____________

 

Stocks - Non Mutual Funds (Held by Broker)                          $____________                                  $____________

 

Bonds - Non Mutual Funds (Not Held by Broker)                                                                                  $____________  $____________

 

Bonds - Non Mutual Funds (Held by Broker)                          $____________                                  $____________