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Estate and Elder Law

Client Intake Form for Estate Planners

Dear Visitor:
 
This form is drawn from Matthew Bender’s Modern Estate Planning, Second Edition. To order a copy, please visit the Lexis Bookstore by clicking here.
 
 
Already a Lexis.com subscriber? You can easily access this publication by clicking here.
 
 

 
Estate Planner’s Client Intake Form:
 
PART A: BACKGROUND INFORMATION
 
 
Date: _______________________________
 
Name:  _____________________________
First Middle Last
 
Social Security No: ___________________
 
Date of Birth: ________________________
 
Marital Status: _______________________  
Married / civil union / registered domestic partner / single / divorced /widowed

Home Address:  _____________________
 
Home Tel No: _______________________
 
Cell Phone No: ______________________
 
Email Address: _____________________
 
Citizenship: ________________________
 
Employer: _________________________
 
Business Tel. No: ___________________
 
Business Address: __________________ 
 

Spouse or Domestic Partner: ___________________
 
Name: ______________________________________  
First Middle Last

Social Security No: ___________________________
 
Date of Birth: ________________________________

Citizenship: _________________________________
 
Home Address: ______________________________
 
Home Tel No: ________________________________
 
Employer: ___________________________________
 
Business Tel. No: _____________________________
 
Business Address: ____________________________

 
Children (please indicate if adopted):
 
Name
Date of Birth
Social Security Number
 
                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Parents, Siblings and Grandchildren (if living):
 
Name
Date of Birth
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Special Family Considerations: For example: prior marriages, alimony/child support obligations, other family obligations (such as aging parents or adult children/siblings w/ special needs, personal or spousal health problems, financial management concerns, etc.

______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
 
Note: 
1. Please furnish copies of any prior wills, trusts, living wills, financial powers of attorney, health-care powers of attorney previously executed by you, your spouse or partner.
2. Indicate preferences for anatomical donations and funeral arrangements.
3. If you are divorced and paying spousal and/or child support, please supply copies of court decrees, agreements, etc.  

 
PART B: ASSET SUMMARY
 
Type
Asset #1 (Also indicate location – bank, brokerage)
Asset #2 (Also indicate location – bank, brokerage)
Indicate: Jointly owned? Client’s sole property? Right of survivorship?
 
 
 
 
a. Cash
 
 
 
b. Checking Accts
 
 
 
c. Saving & Money Mkt Accts
 
 
 
d. Securities (stocks, bonds, mutual funds, etc.)
 
 
 
e. Art & Antiques
 
 
 
f. Other Tangible Personal Property
 
 
 
g. Residential Real Property & Current Value
 
 
 
h. Investment Real Property & Current Value
 
 
 
i. Business Interests (type of entity &  estimated current value)
 
 
 
Subtotal
 
 
 
 
 
 
 
Plus (from following pages)
 
 
 
a. Whole Life Insurance
 
 
 
b. Retirement Plans
 
 
 
c. Other Property
 
 
 
TOTAL:
 
 
 
 
 
 
 
 
 
LIABILITIES
a. Mortgages
 
 
 
b. Other loans
 
 
 
c. Judgments, Settlements
 
 
 
d. Other
 
 
 
TOTAL
 
 
 
 
 
PART C: RETIREMENT, DISABILITY AND DEATH BENEFITS
(For example: annuities, deferred compensation agreements, ESOP’s, 401(k)’s, IRA’s, pensions, profit-sharing plans, self-employed retirement plan stock bonus/options, etc.)
 
Company Plan? Other Type of Plan?
Beneficiary & Current Value
Payment Options
Available
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Note: Please furnish copies of plan or explanatory brochures on each plan.
 
PART D: PROPERTY HELD FOR OTHERS
 
List and describe here:
1. Any property which is held jointly with other persons;
2. Any property held as a "trustee" for others; and
3. Any property held as a "custodian" for others.
4. List any gifts for which federal tax returns have been filed and any other gifts over $5,000. Attach copies of gift tax returns or, if no return has been filed, specify names of donees, dates and amounts.
 
________________________________________________
 
________________________________________________
 
________________________________________________
 
________________________________________________
 
________________________________________________
 
________________________________________________
 
________________________________________________

PART E: OTHER PROPERTY
 
1. Describe any other assets, including intellectual property (such as patents, copyrights, trademarks, goodwill, customer lists, etc.);
2. Potential claims against others;
3. Any trust of which you are a beneficiary or over which you have some involvement, and;
4. Property you may potentially inherit.

________________________________________________
 
________________________________________________
 
________________________________________________
 
________________________________________________
 
________________________________________________
 
________________________________________________
 
________________________________________________


PART F: LIFE INSURANCE

Note: Please furnish copies of policies.
Client
Spouse
 
 
Company:
Company:
Policy No.
Policy No.
Type of Policy:
Type of Policy:
Person Insured:
Person Insured:
Policy Owner:
Policy Owner:
Primary Beneficiary:
Primary Beneficiary:
Contingent Beneficiary:
Contingent Beneficiary:
Face Value:
Face Value:
Cash Value, if any:
Cash Value, if any:
Loan Balance, if any:
Loan Balance, if any:
 
 
 
 
Company:
Company:
Policy No.
Policy No.
Type of Policy:
Type of Policy:
Person Insured:
Person Insured:
Policy Owner:
Policy Owner:
Primary Beneficiary:
Primary Beneficiary:
Contingent Beneficiary:
Contingent Beneficiary:
Face Value:
Face Value:
Cash Value, if any:
Cash Value, if any:
Loan Balance, if any:
Loan Balance, if any:
 

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