Estate Planning Intake Form

1 General Information

First Name

Middle Name

Last Name

Other names / Maiden name

Telephone

Age

Date of Birth

Sex

Male Female

2 Current Residence

Street Number

Street

Town / City

State

Zip Code

Dwelling Type

House Apartment Condominium

If house/condo, owned jointly?

Yes No

Co-owner Name

Co-owner Address

3 Spouse Information

Spouse First Name

Spouse Middle

Spouse Last Name

Spouse Address

If spouse is deceased, please state

Prior marriage — name of ex-spouse

4 Children

List all children

Step-Children

List all step-children

Treatment of Children & Step-Children

Treat the same Divide differently

If dividing differently, specify

5 Grandchildren

6 Great Grandchildren

7 Disinheritance

Family members you do not wish to include in the will

8 In Terrorem (No Contest) Clause

Note: This provision prevents any beneficiary from receiving property under the will if they contest it without good faith and probable cause.

Include In Terrorem Clause?

Yes, include No, do not include

9 Executor / Executrix

Note: An Executor is the person you appoint to carry out the directions in your Will and to dispose of your property according to its provisions. Normally, your spouse would serve unless you designate otherwise.

Primary Executor

Name

Address

Telephone

Substitute (Backup) Executor

Name

Address

Telephone

10 Guardians

Note: If your children are under 18, name a guardian. A guardian does not inherit any portion of your estate unless you so desire. If married, a Guardian is only appointed if both you and your spouse are deceased.

Guardian 1

Name

Address

Phone

Relationship

Guardian 2

Name

Address

Phone

Relationship

11 Trust

Note: If you have children/step-children/grandchildren under 18, you may create a trust whereby property is held until the child reaches age 18 or 21. A Trustee manages the trust funds for the children.

Trustee 1

Name

Address

Phone

Relationship

Trustee 2

Name

Address

Phone

Relationship

12 Bond

Note: Customarily, the Executor, Guardian, and Trustee serve without bond. If any serves with a bond, your estate will have to post the bond premium each year.

Serve without bond?

Yes (recommended) No

13 Assets

13(a) Real Estate

13(b) Personal Possessions

Cars, boats, motorcycles, collections, jewelry, etc.

13(c) Bank Accounts

13(d) Investments (Stocks, Bonds, IRA, 401K, etc.)

13(e) Life Insurance

13(f) Pension

14 Future Inheritance

Do you expect a substantial inheritance within 6 months?

Yes No

15 Property Division — Residuary Clause

Most property will pass through your "Residuary Clause" — this is the rest, residue, and remainder of your estate, rather than specific gifts discussed below. This covers everything other than specific gifts to specific individuals or organizations.

Per Capita: Estate distributed to all living children; if a child predeceases you, their share goes to the remaining children equally.
Per Stirpes: Estate distributed to all living children; if a child predeceases you, their share goes to their children (your grandchildren).

15(a) If Married

Generally, most married people provide that property passes to their surviving spouse, then to children, then to grandchildren, etc. Property can also go to extended family, friends, or organizations. In the event you are not survived by any family, friends, or organizations, you may wish to have property go to a charity rather than let your estate pass to the State.

To surviving spouse If spouse predeceases — divide equally among living children (Per Capita) If spouse & a child predecease — that child's share to their children (Per Stirpes) If spouse, children & grandchildren predecease — pass to alternate Charity

Alternate recipient (option 4)

Charity name (option 5)

15(b) If Unmarried with Children

Most unmarried persons with children provide that property passes to their children, then to grandchildren, etc. Property can also go to extended family, friends, or organizations. In the event you are not survived by any family or friends, you may wish to have property go to a charity rather than let your estate pass to the State.

Divide equally among living children (Per Capita) If a child predeceases — share to their children (Per Stirpes) If all children & grandchildren predecease — pass to alternate Charity

Alternate recipient (option 3)

Charity name (option 4)

16 Custom Distribution

If you do not wish your property to pass in the manner above, describe your preferences.

17 Specific Gifts

Property you wish to go to a particular individual rather than be divided generally.

18 Living Will

Note: A Living Will directs your physician regarding medical care when you are incapacitated. It directs that death not be unreasonably prolonged in terminal situations — it does not intend the direct taking of life.

Do you wish to have a Living Will?

Yes No

Wish to be resuscitated?

Yes No

Kept alive on life support?

Yes No

If life support, for how long?

1 Year 6 Months Other

Other duration (if applicable)

Pain medications if in pain?

Yes No

Blood transfusions?

Yes No

Healthcare Decision Maker

Name

Address

Relationship

Backup Decision Maker

Name

Address

Relationship

19 Final Wishes

Check all that apply and fill in the details.

I wish to be cremated

I wish to have my ashes disposed of as follows:

Details

I wish to have a ceremony

Type of ceremony

I wish to be buried in a specific cemetery

Cemetery name

Cemetery location

I served in the U.S. Military and wish to have a military ceremony

Branch of service

Ceremony type

Other wishes