Estate Planning Intake Form

The following questions are intended to provide us with the information necessary to provide you with the most accurate and
effective estate planning representation possible. We understand that some (if not most) of these questions that you provide will include personal and sensitive information. Please remember that the attorney-client privilege protects this content of this
document, and we will maintain the confidentiality of the information you provide at all times. The nature of your family relations,
and a detailed action of your financial holdings, represent essential information for us to protect your estate planning interests.
‘There are many legal issues that arise in this regard, and we cannot address those issues without accurate information. Thank you.

"*" indicates required fields

Date:*

MM slash DD slash YYYY

How Did You Hear About Us:*

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Client #1 Name:*

Client #2 Name:

Preferred Name:

Age:

Please enter a number from 1 to 99.

Age:

Please enter a number from 1 to 99.

Occupation:

Preferred Phone:

Secondary Phone:

Email:*

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Home:

Address:

Family Information

Marital Status:

Married

Single

Divorced

Widowed

Registered Domestic Partners

Children:

Full Name

BirthDate

MM slash DD slash YYYY

Please indicate one of the following:

Client#1's

Client#2's

Both

Adopted

Full Name

BirthDate

MM slash DD slash YYYY

Please indicate one of the following:

Client#1's

Client#2's

Both

Adopted

Full Name

BirthDate

MM slash DD slash YYYY

Please indicate one of the following:

Client#1's

Client#2's

Both

Adopted

Full Name

BirthDate

MM slash DD slash YYYY

Please indicate one of the following:

Client#1's

Client#2's

Both

Adopted

Grandchildren

Names and ages of any grandchildren you wish to specifice'ly leave a gift (other than receiving from their parent)

FINANCIAL INFORMATION

Estimate the gross fair market value, EXCLUDING insurance, of all of your assets

Over$2,000,000

Over$1,000,000

$750,000-$1,000,000

$500,000-$750,000

Under$500,000

Do you own real estate (including family residence)?

Address

Street Address City State / Province / Region

How is title held?

Community

Joint Tenancy

Separate

Tenants in Common

Fair Market Value

Indebtedness

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Address

Street Address City State / Province / Region

How is title held?

Community

Joint Tenancy

Separate

Tenants in Common

Fair Market Value

Indebtedness

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Address

Street Address City State / Province / Region

How is title held?

Community

Joint Tenancy

Separate

Tenants in Common

Fair Market Value

Indebtedness

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GENERAL ESTATE PLAN PREPARATION INFORMATION

Do you currently have a will or trust?

WILL

TRUST

If so, specify which (will or trust), and when and where the same was executed:

Do you have a pre-nuptial agreement?

Are you or any of your intended beneficiary currently receiving government benefits (Medi-Cal, SSI, etc.) due to a physical or mental disability?

Please answer the following questions:

1. Are you a citizen of the United States?

Client#1

YES

Client#2

YES

2. Are you a resident of the United States?

Client#1

YES

Client#2

YES

3. Are you a California resident?

Client#1

YES

Client#2

YES

4. Have you been married prior to your current status?

Client#1

YES

Client#2

YES

5. Do you have continuing obligations under a divorce?

Client#1

YES

Client#2

YES

6. Do you own a business?

Client#1

YES

Client#2

YES

7. Do you have any retirement plan assets?

Client#1

YES

Client#2

YES

8. Do you own separate property?

Client#1

YES

Client#2

YES

9. Do you anticipate inheriting property sometime soon?

Client#1

YES

Client#2

YES

10. Have you made gifts to anyone over $16,000 in one year?

Client#1

YES

Client#2

YES

TRUST AND WILL PREPARATION INFORMATION

Will you serve as initial Trustee(s) of your Trust?

Trustees/Executors: (the person you name should be the person you want to carry out the wishes and distribute the assets in your trust/will should you become incapacitated or die)

Successor Trustee/Executor

Successor Co-Trustee/Executor

Alternate Successor Trustee

Alternate Successor Co-Trustee

Second Alternate Successor Trustee

Second Alternate Successor Co-Trustee

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Guardians: (the person you name should be the person you want to raise your children should you become incapacitated or die)

Guardian(s)

Alternate Guardian(s)

Guardians: (the person you name should be the person you want to raise your children should you become incapacitated or die)

Are your children your primary beneficiaries?

Yes

please list your primary beneficiaries:

Are they to receive equal shares?

Yes

please list the name and the amount they are to receive:

If a child predeceases you, do you want their share to go automatically to their children?

Yes

please list the name you want each child's share to go to:

Distribution of Assets:

If married, are any assets to be distributed at the first death?

Yes

please list the assets and the beneficiaries:

Distribution of Assets Cont.:

Is your estate to be distributed to your beneficiaries immediately upon the survivors death?

If no, please list when you would like the beneficiaries to receive their distribution: (Example: 1/3 at age 21, 1/3 at age 25, 1/3 at age 30)

If none of the listed beneficiaries are living, please list whom you would like as alternate beneficiaries:

Do you have a special needs child or beneficiary?

Yes

Please name him/her below:

Do you intend to disinherit any of your children?

Yes

Please name him/her below:

ADVANCED HEATLH CARE DIRECTIVE/POWER OF ATTORNEY

Please list the names of the persons to whom you will give the power to make medical decisions for you in the event you are unable to do so yourself.

Client #1

Client #2

Name

Address

Phone

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1st Alt:

Address

Phone

Life Support:

Yes

Life Support:

Yes

Pain Relief:

Yes

Pain Relief:

Yes

Organ Donation:

Yes

Organ Donation:

Yes

Autopsy:

Yes

Autopsy:

Yes

Burial Instructions:

After your spouse/significant other, who do you want to have Power of Attorney to make financial decisions:

Name:

1st Alt:

SUMMARY OF FINANCIAL INFORMATION

Client:

Asset Accounts:

Type

Location AND Last 4 of Acct #

Approximate Balance

Bank

Location AND Last 4 of Acct #

Approximate Balance

Asset Account

Location AND Last 4 of Acct #

Approximate Balance

Brokerage Account

Location AND Last 4 of Acct #

Approximate Balance

Cert. Of Deposit

Location AND Last 4 of Acct #

Approximate Balance

Stocks

Location AND Last 4 of Acct #

Approximate Balance

Bonds

Location AND Last 4 of Acct #

Approximate Balance

Other

Location AND Last 4 of Acct #

Approximate Balance

Other

Location AND Last 4 of Acct #

Approximate Balance

TOTAL:

Total Amount

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Real Property:

Location

Value

Location

Value

TOTAL:

Total Amount

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Retirement Accounts (including IRA's)

Note: Although these accounts are usually NOT transferred into a trust, we would like to see copies of the statements nonetheless, so that we may more accurately make the determination whether or not they should be included.

Type of Plan

Name of Institution

Account Balance

Type of Plan

Name of Institution

Account Balance

TOTAL:

Total Amount

Life Insurance Death Benefits:

Whole/Term, etc.

Name of Institution

Policy Limit

Whole/Term, etc.

Name of Institution

Policy Limit

TOTAL:

Total Amount

Debts:

Credit Cards

Vehicle Loans

Home Mortgage

Other Real Estate

Personal Loans

Other

TOTAL:

Total Amount

Total Assets:

Total Debts:

NET WORTH:

Please List Any Other Information You Think Will Be Helpful, Or Any Questions You Might Have:

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* FOR INTERNAL USE ONLY*

FEE SCHEDULE

Basic Package:

Recording Deed:

Prep Addl Deed(s):

Rec Addl Deed(s):

Addl Docs:

TOTAL:

DEP:

50% due at initial meeting Due upon execution

BAL: