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ESTATE
PLANNING PERSONAL DATA SHEET (SINGLE)
Date_______________ Home Telephone_____________________
Business Telephone
______________________
This form is extremely important. Your accuracy and completeness in responding will help me best represent you.
Bring this information with you to the appointment. Please list names as they would appear on legal documents.
PERSONAL DATA
Full Name ____________________________________________
(print name as shown on your checks)
Address ____________________________________________
Zip
______________________
Birth Date ______________________Social Security Number ______________________
U.S. Citizen? Yes ________ No ________ Annual Income ___________________
If widowed, please list date of death of spouse________________________________________________
REFERRAL
By whom were you referred to this office?
Name ______________________
Address ______________________
DISPOSITIVE INTENTIONS
1. For whom do you want to provide in your Will?
____________________________________________
2. If you have children, do you wish to treat all of your children equally?
Yes ________ No ________
After your death, at what age do you want distribution to your children:
(e.g. a typical plan provides for 1/3 at age 25, 1/3 at age 30 and 1/3 at age 35)
Your choice of age:
________________
3. If you have grandchildren, do you wish to leave a specific amount of
money or a percentage of your estate to your grandchildren?
Yes ________No ________
If so, how much and to whom?
________________________________________
Your choice of age: ________________
4. Do you want to leave a specific amount of money or other assets to any charity?
Yes ________No ________
If so, how much? ________________________
Name and Address of Charity:
________________________________
________________________________
5. Is there any family member that you want to specifically exclude from receiving anything under
your Will?
Yes ________No ________
If so, whom? ________________________________
EXECUTOR
Who do you wish to serve as your Executor?
First Choice ________________________________
Second Choice ________________________________
TRUSTEE
Who do you want to serve as your Trustee?
First Choice ________________________________
Second Choice ________________________________
GUARDIAN
If you have minor children, who do you want to act as Guardian?
First Choice ________________________________
Second Choice ________________________________
LIVING WILL
Do you want your Living Will to provide for withdrawal of artificial food and fluid?
Yes________ No________
Do you want to donate your eyes or organs?
Yes________ No________
Do you want your health care representative to consult with any other person prior to acting?
Yes________ No________
Name of proposed Health Care Agent (usually family member or friend)
________________________________________________
Address of proposed Health Care Agent
________________________________________________
Zip
________________
What is the name, address and telephone number of your primary care physician?
________________________
________________________
________________________
POWER OF ATTORNEY
Name of proposed Financial Agent (usually family member or friend)
________________________________
Address of proposed Financial Agent
________________________________
Zip
________________
Name of proposed Alternate Financial Agent
________________________________________
Address of proposed Alternate Financial Agent
________________________________________
Zip
________________
MISCELLANEOUS
Do you have any other legal issues which I should be aware of?
Yes________ No________
If yes, please explain:
________________________________________________________________
________________________________________________________________
________________________________________________________________
CHILDREN (if applicable)
| CHILD'S
NAME |
ADDRESS
WITH ZIP CODE
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DATE
OF BIRTH
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GRANDCHILDREN (if applicable)
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GRANDCHILD'S
NAME
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ADDRESS
WITH ZIP CODE
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DATE
OF BIRTH
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w-data.sgl
rev. 7/29/98
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CLIENT ASSET INFORMATION
INTAKE FORM
SINGLE
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Name of Client: ________________________________________________
LIABILITIES
ASSETS
Bank Accounts
$____________
$____________
Real Estate (residence)
$____________
$____________
Real Estate (other)
$____________
$____________
Savings Certificates (CD's)
$____________
$____________
Stocks - Non Mutual Funds (Not Held by Broker)
$____________
$____________
Stocks - Non Mutual Funds (Held by Broker)
$____________
$____________
Bonds - Non Mutual Funds (Not Held by Broker)
$____________
$____________
Bonds - Non Mutual Funds (Held by Broker)
$____________
$____________
Mutual Funds
$____________
$____________
Note and Mortgages Receivables
$____________
$____________
Business Interests
$____________
$____________
Inheritance, etc.
$____________
$____________
Automobiles
$____________
$____________
Jewelry & Collections
$____________
$____________
Non-IRA Tax Qual. Retirement Plans
$____________
$____________
IRA's
$____________
$____________
Life Insurance
$____________
$____________
Annuities
$____________
$____________
Other Assets
$____________
$____________
TOTALS
$____________
$____________
The undersigned hereby represents to Law Offices of
Steven Feldman,
and each of its attorneys that the information contained in this intake
form is accurate and complete, and that the undersigned understands
that the law firm and its individual lawyers will rely on this
information which I am furnishing. I understand that if the information
contained herein is inaccurate or incomplete, the recommendations made
by the law firm may not be appropriate.
Signature of Client or Client Representative:
X________________________________________
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