Personal Information
Client #1 Full Legal Name
Birth Date
MM slash DD slash YYYY
U.S. Citizen
- Yes
- No
Status
- Married
- Widowed
- Single
- Life Partner
- Previously Divorced
Client #2 Full Legal Name
Birth Date
MM slash DD slash YYYY
U.S. Citizen
- Yes
- No
Status
- Married
- Widowed
- Single
- Life Partner
- Previously Divorced
Home Address
City
State
ZIP
Home Phone
Cell Phone #1
Cell Phone #2
Ocupation Client #1
Employer
Ocupation Client #2
Employer
Email Address Client #1
Email Address Client #2
Children and/or Other Family Members or Beneficiaries

Use full legal name

Name	Address	Phone / Email	D.O.B.	Relationship

Do any of your children and/or other family members or beneficiaries receive SSI or any other governmental benefits?
- Yes
- No
Important Family Questions
Do you have a will, trust, or other estate planning document?
Client #1
- Yes
- No
Client #2
- Yes
- No
Do you or any of your children or other beneficiaries have disabilities, serious health problems or other special needs?
Client #1
- Yes
- No
Client #2
- Yes
- No
Do you own a business?
Client #1
- Yes
- No
Client #2
- Yes
- No
Do you own a long-term care (nursing home) insurance policy?
Client #1
- Yes
- No
Client #2
- Yes
- No
Are you currently the beneficiary of anyone else's trust?
Client #1
- Yes
- No
Client #2
- Yes
- No

Income & Asset Information
Please list your income and asset information in the appropriate section below.
Earned Monthly Income From
Client #1
Client #2
Labor
Client #1
Client #2
Monthly Social Security
Client #1
Client #2
Monthly Pension
Client #1
Client #2
Other Sources
Client #1
Client #2
Total
Client #1
Client #2
Assets
NOTE: please click the “+” sign to add additional items

Real Property

Please list any interest in real estate that you may have. Please include your family residence, any commercial or investment property, vacation homes, time-shares or vacant land.

General Description and/or address	Owners	Market Value	Equity (approx)

Bank Accounts

Please list all bank account information (i.e., checking, savings, money market accounts & certificates of deposit). Please do not include IRAs or 401 (k) information here.

Bank	Account Type (Checking, Savings, Other)	Owner(s)	Balance

Stocks, Bonds & Mutual Funds

Please list any and all stocks and bonds that you may own and that may be held in a brokerage account (i.e., Morgan Stanley, Edward Jones, e-Trade, etc.) and/or mutual funds that you may own with a mutual fund company. If you own different stocks and/or different mutual funds with the same brokerage company please just "lump them together" under each account. Please do not include IRAs or 401 (k) information here.

Brokerage/Mutual Fund Company	Account Type (Checking, Savings, Other)	Owner(s)	Amount

Retirement Accounts

Please list any and all IRAs, SEPs, 401 (k)s, 403(b)s, pension or retirement plans, the type of qualified account or plan that it is (i.e, a 401 (k), IRA, SEP, etc.), the owner of the account and the current value of the account.

Financial Company	Account Type	Owner(s)	Balance

Life Insurance Policies and Annuities

Please list all life insurance policies (including term, whole life, group life) and annuities.

Financial Company	Account Type	Owner(s)	Balance

Business Interests

Please identify any sole propietorships, privately owned corporations, general or limited partnerships, limited liability companies or limited liability partnerships in which you may have an interest.

Name and Description of the Business	Owner	Percentage Interest	Value (Approx.)

Valuable Personal Property

Please list separately only major personal effects such as jewelry, antique automobiles, boats, furs, pieces of artwork, antiques and all other valuable non-business personal property.

Description of Personal Property	Owner	Value (Approx.)

Money Owed to You

Please list all money owed to you whether by promissory note, oral agreement and/or mortgages

Name of Debtor and Date of Note/Loan	Maturity Date	Owed to Whom	Balance

Estate Plan Design Information
(Persons to act if you are unable.)

Guardians for Minor Children

If you have any children under 18, list in order of preference anyone whom you would want to raise them and love them in the manner as close as possible to the way you would.

Name	Address	Phone number	Email	Relatioship to You/Your children

Guardians for Pets

If you have pets, please identify the pets name and Type of Pet.

Pets Name	Type of Pet

Guardians for Pets

Please name anyone whom you would want to care for your pets.

Name	Address	Phone number	Email

Financial Desicion Makers/Trustee

On the death or disability of both of you, whom do you want making financial decisions about the management and distribution of your assets to your beneficiaries? (It does not need to be the same people whom you've named as guardians of any minor children).

Name	Address	Phone number	Email	Relatioship

Health Care Decision Makers
If you were unable to make health care decisions for yourself, whom would you want to make those medical decisions?

Client #1's Health Care Agent(s)

List in order of preference.

Name	Address	Phone number	Email	Relatioship

Do you wish to provide the moment of your death not be unnecessary prolonged by artificial means or measures?
- Yes
- No
Please Initial
Did you wish to provide that your organs and tissues be made available for transplant purposes?
- Yes
- No
Please initial

Client #2's Health Care Agent(s)

List in order of preference.

Name	Address	Phone number	Email	Relatioship

Do you wish to provide the moment of your death not be unnecessary prolonged by artificial means or measures?
- Yes
- No
Please Initial
Did you wish to provide that your organs and tissues be made available for transplant purposes?
- Yes
- No
Please Initial

Legal/Financial Decision Makers (i.e., "Durable Power of Attorneys")
If you weren't able to make the financial decisions for yourself because of a legal incapacity such as severe stroke or Alzheimer's, whom would you like to make legal decisions for you? (they do not have to be the same people who are making healthcare decisions for you).

Client #1's Attorney if Fact ("Powers if Attorney")

List in order of preference.

Name	Address	Phone number	Email	Relatioship

Do you wish your Attorney in Fact to only have decision making of authority when you become legally incapacitated?(Known as "contingent" or "springing" Power of Attorney because it takes place at the time of a future event, i.e., your legal incapacity). Or, do you wish for your attorney in fact to have immediate authority to make legal decisions for you?
- I would like my Attorney in Fact to only have authority when they became legally incapacitated in the future
- I will like my Attorney in Fact to have authority immediately on signing my documents
Please Initial
Do you wish to give your Attorney in Fact the authority to make gifts for you while you are legally incapacitated, even to him or herself? (this could be helpful for medical planning purposes)
- Yes
- No
Please Initial

Client #2's Attorney if Fact ("Powers if Attorney")

List in order of preference.

Name	Address	Phone number	Email	Relatioship

Do you wish your Attorney in Fact to only have decision making of authority when you become legally incapacitated?(Known as "contingent" or "springing" Power of Attorney because it takes place at the time of a future event, i.e., your legal incapacity). Or, do you wish for your attorney in fact to have immediate authority to make legal decisions for you? (Please select an initial one)
- I would like my Attorney in Fact to only have authority when they became legally incapacitated in the future
- I will like my Attorney in Fact to have authority immediately on signing my documents
Please Initial
Do you wish to give your Attorney in Fact the authority to make gifts for you while you are legally incapacitated, even to him or herself? (this could be helpful for medical planning purposes)
- Yes
- No
Please Initial

Final Disposition Instructions
Generally speaking, at the time of your death, your "next of kin" (i.e., your surviving spouse, your surviving adult children, your surviving parent(s), your surviving sibling(s), in that order) will the authority to make decisions about the handling an arrangement for your remains. If you have not spoken with your family about how you envision your funeral arrangement or the disposition of your remains, then it will be left to them to decide and their decisions may not be in line with your intentions. And, if those left behind all have different expectations of how to prepare your arrangements, arguments and hurt feelings can result. For these reasons, the more detailed instructions that you leave, the easier it will be for your survivors to satisfy your wishes. While it is a difficult an uncomfortable topic to consider, we ask you to try and answer the following questions
Client #1's Final Disposition Instructions
At my death I wish to be
- Cremated
- Buried
I would like my ashes to be
I would like my remains interred at
I have not made burial arrangements yet
I have made burial arrangements at

The people to whom I give authority to carry out my wishes shall be in the following order of priority

Name	Address	Telephone Number	Relationship to you

Client #2's Final Disposition Instructions
At my death I wish to be
- Cremated
- Buried
I would like my ashes to be
I would like my remains interred at
I have not made burial arrangements yet
I have made burial arrangements at

The people to whom I give authority to carry out my wishes shall be in the following order of priority

Name	Address	Telephone Number	Relationship to you

Thank you for completing this form. Please add your email address in the box below, and you’ll receive a PDF at that address of your completed form (please check your junk folder if you don’t receive an email in your “In” box).*

Step 1 of 6

Personal Information

Children and/or Other Family Members or Beneficiaries

Important Family Questions

Income & Asset Information

Assets

Estate Plan Design Information

Health Care Decision Makers

Legal/Financial Decision Makers (i.e., "Durable Power of Attorneys")

Final Disposition Instructions

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