DOC

CONFIDENTIAL

By Kimberly Baker,2014-07-09 20:53
9 views 0
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 __________________________ __________________________________ rd3 __________________________ __________________________________ th4 __________________________ __________________________________

FOR WIFE: (In order of preference)

    Name: Address (Street, City, State, Zip) st1 _____________________________ _____________________________________ nd2 __________________________ __________________________________ rd3 __________________________ __________________________________ th4 __________________________ __________________________________

MEDICAL INSTRUCTIONS:

    HEALTH CARE POWER OF ATTORNEY

    If you were unable to make medical decisions for yourself, who would you want to make

    decisions for you with regard to medical treatment and/or life support machines?

FOR HUSBAND: (In order of preference)

    Name: Address (Street, City, State, Zip & Phone No.) st1 _____________________________ _____________________________________ nd2 __________________________ __________________________________ rd3 __________________________ __________________________________ th4 __________________________ __________________________________

FOR WIFE: (In order of preference)

    Name: Address (Street, City, State, Zip & Phone No.)

     st1 _____________________________ _____________________________________ nd2 __________________________ __________________________________ rd3 __________________________ __________________________________ th4 __________________________ __________________________________

     5

OTHER DEPENDENTS

     Do you or your spouse have anyone who depends on either of you for all or part

    of their support?

     YES NO

If YES:Name __________________________ Relationship ___________________

QUESTIONS ABOUT YOUR CHILDREN OR OTHER BENEFICIARIES

    (Circle Yes or NO)

    1. Do any of your children or beneficiaries receive governmental

    support or benefits because of a disability or handicap? YES NO

     2. Do any of your children or beneficiaries have special educational,

     medical, or physical needs? YES NO

     3. Are any of your children or beneficiaries institutionalized? YES NO

     4. If you answered YES to any of the above questions, please describe the type of disability that

     your child or beneficiary has: __________________________________________________

     _____________________________________________________

    5. Do any of your children or beneficiaries have any other special needs or circumstances

    that are concerns to you? YES NO

    If YES, please describe:

    ______________________________________________________________________

     _________________________________________________________________

     ___________________________________________

IF ANY OF YOUR CHILDREN ARE UNDER THE AGE OF 18

Whom do you wish to be guardian of your children?

Name in order of preference. (One person per line)

1. Name ______________________________ Relationship __________________

    2. Name ______________________________ Relationship __________________

    3. Name ______________________________ Relationship __________________

    4. Name ______________________________ Relationship __________________

     6

    PERSONAL INFORMATION BACKGROUND

QUESTIONS ABOUT YOU AND YOUR SPOUSE

1. Are you or your spouse receiving social security or

     disability benefits? YES NO

2. Do you or your spouse have any health concerns? YES NO

    If YES, what? __________________________________________

3. Have you lived in any of the following states while married to

    your current spouse? (WA, ID, CA, NE, AR, NM, TX, LA, WI) YES NO

    If YES, list which state(s) and the time period your resided there.

    State _____ Dates _______ State _____ Dates _______

    4. Have you or your spouse ever filed federal gift tax returns? YES NO

    5. Are you currently making annual gifts to anyone? YES NO

    6. Did you and your spouse ever sign a pre/post-marriage contract? YES NO

    7. Have either of you ever been divorced? YES NO

    If YES, whom _____________ date ________________

    8. Have either of you ever been widowed? YES NO

    If YES, whom _____________ date ________________

    9. Do you desire to benefit any charities in your estate plan? YES NO

    If YES, name the charities___________________________________

    10. Are you currently the beneficiary of anyone else’s trust? YES NO

    If YES, briefly describe ____________________________________________

    ________________________________________________________________

YOUR ADVISORS:

     Name City/State Telephone

    Attorney: _______________________________________________________________

    Accountant: _____________________________________________________________

    Financial Planner _________________________________________________________

    Life Ins. Agent ___________________________________________________________

    Life Ins. Agent ___________________________________________________________

     7

Primary Pers. Bank _______________________________________________________

    Primary Bus. Bank ________________________________________________________

    INSTRUCTIONS FOR COMPLETING

    THE PERSONAL INFORMATION CHECKLIST

General Headings This Personal Information Checklist is designed to help you list

    all the property you own, how it is titled, and its value. If you

    own more property than can be listed on this checklist, use extra

    sheets or paper to list your additional property.

Type Immediately after the heading for each kind of property is a brief

    explanation of what property you should list under that heading.

“Owner” of Property How you own your property is extremely important for purposes

    of properly designing and implementing your estate plan. For

    each property category, there is a column titled “Owner.” When

    filing in this column, please use the following abbreviations:

    For Property With: Use:

    Owned By:

    If you are single and you own Single property in your name only, use I

    Client #1’s No other person C1

    Client #2’s No other person C2

    Joint A spouse JTS

    Tenancy

    Joint Someone other than a JTO

    Tenancy spouse

    Tenancy A spouse TCS

    in Common

    Unknown If you cannot determine ?

    how the property is owned

     8

    YOUR CONCERNS

    Please rate the importance to you of the following concerns: Least -----Most

PROTECTION FOR YOUR CHILDREN 1 2 3 4 5

PROTECTION FOR YOUR SPOUSE 1 2 3 4 5

MAINTAINING CONTROL OF YOUR ASSETS 1 2 3 4 5

AVOIDING PROBLEMS IN CASE OF MENTAL DISABILITY 1 2 3 4 5

AVOIDING LIFE SUPPORT MACHINES 1 2 3 4 5

AVOIDING PROBATE 1 2 3 4 5

AVOIDING OR REDUCING ESTATE TAXES 1 2 3 4 5

AVOIDING OR REDUCING INCOME TAXES 1 2 3 4 5

DISINHERITANCE OF A FAMILY MEMBER 1 2 3 4 5

PROTECTING ASSETS FROM LAWSUITS, ETC. 1 2 3 4 5

RETAINING FAMILY MANAGEMENT OF FINANCIAL AFFAIRS 1 2 3 4 5

OTHER CONCERNS (Please list below):

_________________________________________________________

    _________________________________________________________

    _________________________________________________________

    In addition to discussing any of the above concerns, we will discuss the following topics:

     Who is to receive your assets after your death?

     What instructions do you want to leave for the benefit of yourself and your loved ones?

     Who would manage and distribute your assets after your death or during your disability?

     9

    LIABILITIES

     DOLLAR AMOUNTS

    LIABILITIES JOINT HUSBAND WIFE Loans Payable

    Accounts Payable

    Real Estate Mortgage Residence

    Real Estate Mortgage

    Loans Against Life Insurance

    Other Obligations

    TOTAL LIABILITIES

    CURRENT INCOME AND SOURCES

     DOLLAR AMOUNTS

     JOINT HUSBAND WIFE Salary and Wages

    Investment Income and Dividends

    Social Security

    Pension or Retirement Plans

    Other

    TOTAL

     10

Report this document

For any questions or suggestions please email
cust-service@docsford.com