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CONFIDENTIAL

By Kimberly Baker,2014-07-09 20:53
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CONFIDENTIAL ...

    CONFIDENTIAL

    ESTATE PLANNING

    INTAKE INFORMATION

Family Information and Asset Summary

    CHAMBERS LAW, PLLC

    4140 Parklake Avenue, Suite 615

    Raleigh, NC 27612

    Phone: 919-277-2200 Fax: 919-277-2525

    PERSONAL INFORMATION YOU

    Date Prepared: _________________ Referred by: _________________

CLIENT:

    Full Legal Name _____________________________________________________

    Name Used to Sign Legal Documents______________________________________ Prefer to be Called___________________________

    Home Address _______________________________________________________ City _____________________ State ____________________ Zip Code ____________

    County _________________ Home Phone ________________ Soc. Sec. No. ________________

    Date of Birth ___________ Age ______ U. S. Citizen? YES NO

Employer ________________________________________

    Business Address ___________________________________________

    City _____________________ State __________ Zip Code _________

    Business Phone _______________________ Own Business? YES NO

    Please provide your email address: ___________________________________

SPOUSE:

    Full Legal Name _____________________________________________________

    Name used to sign legal documents_______________________________________

    Prefer to be Called________________ Soc. Sec. No.___________________

    Date of Birth ___________ Age ______ U. S. Citizen? YES NO

Employer ________________________________________

    Business Address ___________________________________________

    City _____________________ State __________ Zip Code _________

    Business Phone _______________________ Own Business? YES NO

    Please provide your email address:_______________________________________

On what date were you married? _____________

    Have you or your spouse previously completed will, trust, or estate planning? YES* NO

     If YES, what kind of planning and when? ________________________________

    *It would be helpful for you to bring existing wills and/or trusts to your consultation for review

     2

    PERSONAL INFORMATION YOUR BENEFICIARIES

YOUR CHILDREN:

    Please indicate any children who are adopted. Under “comments”, please describe your

    relationship with this child, his or her spouse or partner, and grandchildren. Do you have any

    specific wishes with respect to their inheritance?

    H=Husband, W=Wife, B=Both Age Full Legal Name (spell out middle names) Birth Date Child of ____ _______________________________________ _________ _______

    Social Security Number______________________________________

    Occupation ________________________________________________

    Education _________________________________________________

    Spouse’s name _____________________________________________

    Grandchildren & their ages ___________________________________

     ____________________________________

     ____________________________________

    Comments ______________________________________________________________

    _______________________________________________________________________

    _______________________________________________________________________

    Age Full Legal Name (spell out middle names) Birth Date Child of ____ _______________________________________ _________ _______

    Social Security Number______________________________________

    Occupation ________________________________________________

    Education _________________________________________________

    Spouse’s name _____________________________________________

    Grandchildren & their ages ___________________________________

     ____________________________________

     ____________________________________

    Comments ______________________________________________________________

    _______________________________________________________________________

    _______________________________________________________________________

    Age Full Legal Name (spell out middle names) Birth Date Child of ____ _______________________________________ _________ _______

    Social Security Number______________________________________

    Occupation ________________________________________________

    Education _________________________________________________

    Spouse’s name _____________________________________________ Grandchildren & their ages ___________________________________

     ____________________________________

     ____________________________________

    Comments ______________________________________________________________

    _______________________________________________________________________

    _______________________________________________________________________

     3

    Age Full Legal Name (spell out middle names) Birth Date Child of ____ _______________________________________ _________ _______

    Social Security Number______________________________________

    Occupation ________________________________________________

    Education _________________________________________________

    Spouse’s name _____________________________________________ Grandchildren & their ages ___________________________________

     ____________________________________

     ____________________________________

    Comments ______________________________________________________________

    _______________________________________________________________________

    _______________________________________________________________________

    Age Full Legal Name (spell out middle names) Birth Date Child of ____ _______________________________________ _________ _______

    Social Security Number______________________________________

    Occupation ________________________________________________

    Education _________________________________________________

    Spouse’s name _____________________________________________ Grandchildren & their ages ___________________________________

     ____________________________________

     ____________________________________

    Comments ______________________________________________________________

    _______________________________________________________________________

    _______________________________________________________________________

    Age Full Legal Name (spell out middle names) Birth Date Child of ____ _______________________________________ _________ _______

    Social Security Number______________________________________

    Occupation ________________________________________________

    Education _________________________________________________

    Spouse’s name _____________________________________________ Grandchildren & their ages ___________________________________

     ____________________________________

     ____________________________________

    Comments ______________________________________________________________

    _______________________________________________________________________

    _______________________________________________________________________

     4

    PERSONS TO ACT FOR YOU

GENERAL INSTRUCTIONS:

    DURABLE FINANCIAL POWER OF ATTORNEY

If you were unable and your spouse was unavailable to make decisions for yourself, who would

    you want to make decisions for you with regard to your property and assets? You may name a

    husband and wife on one line if you wish them to serve together.

FOR HUSBAND: (In order of preference)

    Name: st1 _____________________________ _____________________________________ nd2 __________________________ __________________________________