On-Line Form

Your name:
Email address:

Client/Client

a.	Name:
b.	Birth Date:
c.	Social Security #:
d.	Name:
e.	Birth Date:
f.	Social Security #:
g.	Citizens of What Country:
h.	Address:
i.	City:		County:
j.	State:		Zip:
k.	Home Phone:		Work Phone:
l.	Cell Phone 1:		Cell Phone 2:
m.	E-mail:
n.	Are you on Facebook?:	Yes    No
o.	Have you ever been married before?	Yes    No	Referred by whom?
p.	By whom are your financial assets managed?

Children
(Omitted children must be specifically mentioned as being omitted otherwise they may have a claim to your estate.  Therefore, list all children including any deceased children.)  Please specify if you have any children born out of wedlock.

Name	Date of Birth	Married Name	Address	Phone

Please list all grandchildren. 
Please specify if you have any illegitimate grandchildren (including grandchildren born before your children were ever married.

Name	Date of Birth	Married Name	Address

Whom do you want to be guardian & successor guardian of your children?



Address?



Whom do you want to be your executor & successor executor?



Address?



Do you wish to have a trust established for the benefit of your spouse and/or children or grandchildren?

a.  Whom do you want as trustee & successor trustee?


Address?


b.  At what age or ages would you want your children (or grandchildren) to receive distribution of the trust?



If no family members survived you, who would you want to receive your money? 
(Do you have any specific charitable interests?)



Children and Grandchildren as Beneficiaries.

a. Have any children or grandchildren received an advance on their inheritance or are any children financially
indebted to you?
Yes
No

b. Do you want your children treated equally?
Yes
No

c. Do you want your grandchildren treated equally?
Yes
No

d. Are any of the children or grandchildren not responsible with money?
Yes
No

e. Are any of the children or grandchildren under a disability?
Yes
No

f. If any of your children should predecease you, should your child's share pass to his/her child (your grandchildren)?
Yes
No


What are the approximate values of your current assets and any outstanding debt?
(Do you have a net worth statement?)

a.	Homestead (Bring copy of warranty deed.)
b.	Other Real Estate (Bring copy of warranty deed.)
c.	Retirement benefits and all beneficiaries. (Change Contingent Beneficiary)
	Managed by whom?
d.	Securities (stocks, bonds, contracts, etc.).
	Managed by whom?
e.	Bank Savings and Certificates.
f.	529 Plan (Education Planning)
g.	Insurance and all beneficiaries (Change Contingent Beneficiary)
	1.  Life (death benefit) (separate policy independent of employer?)
	2.  Disability (Do you have a group or individual disability plan?
	Do you know what the benefits are?
	3.  Long-Term Care Insurance (i.e. Nursing Home Insurance)
	4.  Umbrella Liability (separate policy for individuals and business coverage?)
h.	Other assets such as a business (S Corp Stock?) or substantial personal property?
i.	Annual income including salary and other income.

Do you have a safe deposit box?  Yes  No

a. Location?


b. Who has access?



Are you interested in a Power of Attorney?  Yes  No

Address of Attorney-in-Fact?



Are you interested in a Health Care Directive (i.e., Living Will)?  Yes  No

Name of alternate agent?


If either spouse passed away, what would be the income needs of the surviving spouse? (Would there be a shortfall?)



If either spouse owns a business or is self-employed, what are the monthly overhead expenses?



Do you have a trusted advisor such as an investment consultant, financial planner, accountant, or insurance agent?
Yes  No


Any general concerns or comments?

Please make sure all of the above information is correct to the best of your knowledge.