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CONFIDENTIAL ESTATE PLANNING INTAKE FORM

By Chris Russell,2014-07-09 20:51
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CONFIDENTIAL ESTATE PLANNING INTAKE FORM ...

     Megan & O’Shea LLC

    Reservoir Place

    1601 Trapelo Road, Suite 172

    Waltham, MA 02451

    Main: 781-906-0136

    Fax: 877-780-5898

    CONFIDENTIAL ESTATE PLANNING INTAKE FORM

This form is helpful as we assist you in meeting your estate planning objectives. Please

    fill out as much as possible using estimated figures where information is not easily

    attainable, and leaving blanks for those questions which are inapplicable. Please feel free

    to write in the margins or to add other information that you think might be helpful.

A. Background Information

    Client A Client B

1. Full legal name: ______________________ ______________________

2. Addresses and Phone Number

    Principal Residence: ______________________ ______________________

     ______________________ ______________________

     ______________________ ______________________

     Tel:___________________ Tel:___________________

    Business: ______________________ ______________________

     ______________________ ______________________

     ______________________ ______________________

     Tel:___________________ Tel:___________________

    Cell phone: ______________________ ______________________

    E-Mail: ______________________ ______________________

    Where do you prefer to receive estate planning correspondence?

     Home___ Business___

3. Profession/Business: ______________________ ______________________

4. Dates of Birth: ______________________ ______________________

5. Birthplace: ______________________ ______________________

6. Citizenship: ______________________ ______________________

B. Family Information

    Children

    1. Name: ______________________________ Date of Birth: ___/___/____

     Married? Y___ N___ If so, name of spouse: _______________________

    2. Name: ______________________________ Date of Birth: ___/___/____

     Married? Y___ N___ If so, name of spouse: _______________________

    3. Name: ______________________________ Date of Birth: ___/___/____

     Married? Y___ N___ If so, name of spouse: _______________________

    4. Name: ______________________________ Date of Birth: ___/___/____

     Married? Y___ N___ If so, name of spouse: _______________________

    5. Name: ______________________________ Date of Birth: ___/___/____

     Married? Y___ N___ If so, name of spouse: _______________________

    6. Name: ______________________________ Date of Birth: ___/___/____

     Married? Y___ N___ If so, name of spouse: _______________________

Grandchildren (if any)

    1. Name: ______________________________ Date of Birth: ___/___/____

    2. Name: ______________________________ Date of Birth: ___/___/____

    3. Name: ______________________________ Date of Birth: ___/___/____

4. Name: ______________________________ Date of Birth: ___/___/____

    C. Financial Information

    Approximate Annual Income

    Client A Client B

1. Salary/commissions: ______________________ ______________________

2. Interest/dividends: ______________________ ______________________

3. Bonuses: ______________________ ______________________

4. Other income: ______________________ ______________________

    Approximate Asset Values

    Client A Client B Joint

1. Cash or near cash: ____________ ____________ ____________

2. Investment accounts: ____________ ____________ ____________

3. Homes (est. FMV): ____________ ____________ ____________

4. Other real estate: ____________ ____________ ____________

     (est. FMV)

5. Personal possessions: ____________ ____________ ____________

     (i.e., tangible items)

6. Retirement accounts: ____________ ____________ ____________

7. Insurance cash value: ____________ ____________ ____________

8. Other: ____________ ____________ ____________

     (e.g., S Corp stock,

     other business ____________ ____________ ____________

     interests, intellectual

     property interests, etc.)

    Significant Liabilities (Mortgages, other debts, adverse legal judgments, etc.)

1. Amount and nature of liability:____________________________________

2. Amount and nature of liability:____________________________________

3. Amount and nature of liability:____________________________________

    D. Life Insurance

    Insured Face Value Cash Value Beneficiary Owner

    1. Client A

     Policy #1: ________ ________ ________ ________

     Policy #2: ________ ________ ________ ________

     Policy #3: ________ ________ ________ ________

2. Client B

     Policy #1: ________ ________ ________ ________

     Policy #2: ________ ________ ________ ________

     Policy #3: ________ ________ ________ ________

    E. Other Advisors

1. Accountant

    Name: ______________________

    Address: ______________________

     ______________________

     ______________________

     Phone: ______________________

    2. Investment Manager

    Name: ______________________

    Address: ______________________

     ______________________

     ______________________

     Phone: ______________________

    3. Life Insurance Agent

    Name: ______________________

    Address: ______________________

     ______________________

     ______________________

     Phone: ______________________

F. Special Considerations

1. Do you have any existing estate planning documents (wills, trusts, health care

    proxies, etc.)?

    __________________________________________________________________

    __________________________________________________________________

2. Do you expect to inherit significant wealth from parents or other relatives?

    __________________________________________________________________

    __________________________________________________________________

3. Have you been previously married?

    __________________________________________________________________

    __________________________________________________________________

4. Do you have a pre-marital agreement?

    __________________________________________________________________

    __________________________________________________________________

5. To your knowledge, are you a beneficiary under any existing trusts?

    __________________________________________________________________

    __________________________________________________________________

6. Please give thought to individuals who may be appropriate to serve as Guardians

    of your minor children (if any), Executors, and Trustees.

    __________________________________________________________________

    __________________________________________________________________

7. Have you made any significant gifts of money or property during life?

    __________________________________________________________________

    __________________________________________________________________

G. Estate Planning Objectives

Please describe any significant estate planning objectives or concerns.

    ________________________________________________________________________

    ________________________________________________________________________

    ________________________________________________________________________

    ________________________________________________________________________

    ________________________________________________________________________

    ________________________________________________________________________

    ________________________________________________________________________

    ________________________________________________________________________

    ________________________________________________________________________

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