Intake Form – Husband & Wife – Robert Carlson

CONFIDENTIAL ESTATE PLANNING QUESTIONNAIRE
Don't Email, So that I may provide you with appropriate legal advice, please fill out the following questionnaire as completely as possible. If any question does not apply to you, simply answer by filling in “N/A.”

If possible, please provide each person’s full name as provided on his/her driver’s license.

PERSONAL INFORMATION: Please provide the following information, as applicable:
Full “Driver’s License” Name:
Full “Driver’s License” Name: (Wife)
Former Name:
Former Name (Wife)
SSN (last 4 only)
SSN Wife
Date of Birth
MM slash DD slash YYYY
Date of Birth (Wife)
MM slash DD slash YYYY
Birthplace:
Birthplace: wife
Citizenship:
Citizenship: wife
Occupation:
Occupation:
Employer:
Employer:
Work Phone:
Work Phone:
Cell Phone:
Cell Phone:
Email Address:
Email Address:
Home Telephone:
Home Address:
Mailing Address:
ADVISORS: Please provide the following regarding any advisors you may have:
Any Other Attorneys:
Any Other Attorneys:
Financial Advisor:
Financial Advisor:
Stockbroker:
Stockbroker:
Personal Banker:
Stockbroker:
Accountant:
Accountant:
Life Insurance Agent:
Life Insurance Agent:
Other:
Other:
Referred to Firm By:
Referred to Firm By:
Current Marriage
CURRENT MARRIAGE:
Date and Place of marriage:
During your marriage, Have you lived in any states other than Florida? If so, Please list the states and dates:
State:
From:
To:
State:
From:
To:
Year you and your spouse moved to Florida?
Do you and your spouse have a prenuptial agreement or other formal property agreement?
- Yes
- No
If so, Please furnish a copy of the agreement.
FORMER MARRIAGES:
FORMER MARRIAGES: Please list any former marriages:
Former Spouse’s full name:
Former Spouse’s full name:
Date of Marriage
MM slash DD slash YYYY
Date of Marriage (Wife)
MM slash DD slash YYYY
Date of Dissolution* / Death:
MM slash DD slash YYYY
Date of Dissolution* / Death (wife):
MM slash DD slash YYYY
If a previous marriage ended by dissolution, please furnish a copy of the dissolution papers.
CHILDREN OF CURRENT MARRIAGE
(including adopted children)
Full Name:
Nickname:
D.O.B.
MM slash DD slash YYYY
Address:
Full Name:
Nickname:
D.O.B
MM slash DD slash YYYY
Address:
Full Name:
Nickname:
D.O.B
MM slash DD slash YYYY
Address:
CHILDREN OF CURRENT MARRIAGE
(including adopted children)
Full Name:
Nickname:
D.O.B
MM slash DD slash YYYY
Address:
Parent’s Full Names:
Full Name:
Nickname:
D.O.B
MM slash DD slash YYYY
Address:
Parent’s Full Names:
Full Name:
Nickname:
D.O.B
MM slash DD slash YYYY
Address:
Please add the names of any additional children of this marriage or any former marriage on a separate page.
Do you have any children who have died?
- Yes
- No
If so, did any deceased child have any children who are now living?
- Yes
- No
If yes, Please provide the full name of each living child of the deceased child, as well as each living child’s date of birth and address below:
FAMILY QUESTIONS:
Please provide a brief explanation for any “Yes” answers:
1. Do you or your spouse have any special health or disability concerns?
- Yes
- No
2. Do you or any family members of yours receive governmental support or benefits?
- Yes
- No
3. Does any child have a learning disability, or have special education, medical or physical needs?
- Yes
- No
4. Do you have a child who is institutionalized?
- Yes
- No
5. Do you provide primary or other financial support to an adult child, or to persons other than an adult child?
- Yes
- No
6. Are you or your spouse making payments pursuant to a dissolution or property agreement, including child support payments?
- Yes
- No
7. Have you or your spouse ever filed a gift tax return (either federal or state)? If so, Please furnish copies of the returns.
- Yes
- No
8. If you or your spouse has been widowed, was a federal or state death tax return filed for the deceased spouse?
- Yes
- No
9. Do either you or your spouse want specific funeral arrangements? (Husband)
- Yes
- No
Do either you or your spouse want specific funeral arrangements? (Wife)
- Yes
- No
Please provide a brief explanation for any “Yes” answers above:
CURRENT ESTATE PLAN:
Do you have a will now? If so, date of the will? (Husband)
- Yes
- No
Do you have a will now? If so, date of the will? (Wife)
- Yes
- No
Are you the beneficiary of someone else’s trust? (Husband)
- Yes
- No
Are you the beneficiary of someone else’s trust? (Wife)
- Yes
- No
Have you given someone else a power of attorney? If so, name of agent: Is it still in effect? (Husband)
- Yes
- No
Have you given someone else a power of attorney? If so, name of agent: Is it still in effect? (Wife)
- Yes
- No
Do you have a Florida Advance Directive? (Florida Living Will)? (Husband)
- Yes
- No
Do you have a Florida Advance Directive? (Florida Living Will)? (Wife)
- Yes
- No
Have you named a Health care Representative? If so, please name below with Fiduciaries. (Husband)
- Yes
- No
Have you named a Health care Representative? If so, please name below with Fiduciaries. (Wife)
- Yes
- No
YOUR ESTATE PLANNIG GOALS:
Please list your estate planning goals and any special concerns you may have:
If you wish to leave specific property to specific Individuals, Please describe below:
Persons Full Name: Address:
Property:
Persons Full Name: Address:
Property:
Persons Full Name: Address:
Property:
Persons Full Name: Address:
Property:
Persons Full Name: Address:
Property:
Do you wish the property to go to an individual only if he/she survives you, or if the individual does not survive you, can the property go the individual’s estate?
- To the individual only
- To the individual’s estate, should he/she not survive you
FIDUCIARIES
Select your fiduciaries (i.e., personal representative, guardian, trustee, etc.) which are listed below.

Please insert your tentative choices below. If possible please provide each person’s full name as provided on his/her driver’s license.
Personal Representative (Executor):
The personal representative administers your estate pursuant to the terms of your will, which includes resolving any debts and handling the distribution of your propertyto the beneficiaries
Do you wish to name your spouse as your first choice to be your personal representative?
- Yes
- No
Next choice: Full name(s):
Phone #:
Relationship:
Address:
Next choice: Full name(s):
Phone #:
Relationship:
Address:
Trustee:
The trustee manages the property /funds which are held in trust for the benefit of the surviving spouse, minor children or other beneficiaries.
Do you wish to name your spouse as your first choice to be trustee?
- Yes
- No
Next choice: Full name(s):
Phone #:
Relationship:
Address:
Next choice: Full name(s):
Phone #:
Relationship:
Address:
Guardian for Children:
The guardian cares for your minor children (under age 18) if both parents are unable to care for them.
Next choice: Full name(s):
Phone #:
Relationship:
Address:
Next choice: Full name(s):
Phone #:
Relationship:
Address:
Guardian/Conservator:
The Guardian/Conservator is a court appointed person who handles your affairs and makes decisions on your behalf in the event you are unable to do so for yourself.
Do you wish to name your spouse as your first choice to be Guardian/Conservator?
- Yes
- No
Next choice: Full name(s):
Phone #:
Relationship:
Address:
Next choice: Full name(s):
Phone #:
Relationship:
Address:
Attorney-in-Fact:
The Attorney-in-fact is a person you designated under a power of Attorney to handle your business affairs in the event you cannot do so for yourself.
Do you wish to name your spouse as your first choice to be your Attorney-in-fact?
- Yes
- No
Next choice: Full name(s):
Phone #:
Relationship:
Address:
Next choice: Full name(s):
Phone #:
Relationship:
Address:
Health Care Representative:
The Health Care Representative makes health care decisions for you in the event you cannot make such decisions for yourself.
Do you wish to name your spouse as your first choice to be your Health Care Representative?
- Yes
- No
Next choice: Full name(s):
Phone #:
Relationship:
Address:
Next choice: Full name(s):
Phone #:
Relationship:
Address:
Please use the space below to name any additional fiduciaries:
PROPERTY INFORMATION
Please fill in as completely as possible the information requested below regarding your property. This information will assist me in creating an estate planning strategy, including any tax planning, which will be appropriate for your needs.

Joint ownership of an asset, means that such property shall pass to the surviving joint owner automatically at death by right of survivorship. If any property is jointly held but does not pass without right of survivorship at death, please specify to whom the property shall pass.
1. PROPERTY
Owner’s Name (Husband/Wife/Joint)
Market Value
Debt
Net Equity
2. PROPERTY
Owner’s Name (Husband/Wife/Joint)
Market Value
Debt
Net Equity
3. PROPERTY
Owner’s Name (Husband/Wife/Joint)
Market Value
Debt
Net Equity
4. PROPERTY
Owner’s Name (Husband/Wife/Joint)
Market Value
Debt
Net Equity
1. BANK ACCOUNTS: Provide Bank and Account type
Owner’s Name (Husband/Wife/Joint)
Average Balance
Debt
Net Equity
2. BANK ACCOUNTS: Provide Bank and Account type
Owner’s Name (Husband/Wife/Joint)
Average Balance
Debt
Net Equity
3. BANK ACCOUNTS: Provide Bank and Account type
Owner’s Name (Husband/Wife/Joint)
Average Balance
Debt
Net Equity
4. BANK ACCOUNTS: Provide Bank and Account type
Owner’s Name (Husband/Wife/Joint)
Average Balance
Debt
Net Equity
1. STOCKS, BONDS & MUTUAL FUNDS:
Owner’s Name (Husband/Wife/Joint)
Market Value
Debt
Net Equity
2. STOCKS, BONDS & MUTUAL FUNDS:
Owner’s Name (Husband/Wife/Joint)
Market Value
Debt
Net Equity
3. STOCKS, BONDS & MUTUAL FUNDS:
Owner’s Name (Husband/Wife/Joint)
Market Value
Debt
Net Equity
4. STOCKS, BONDS & MUTUAL FUNDS:
Owner’s Name (Husband/Wife/Joint)
Market Value
Debt
Net Equity
1. NOTES, MORTGAGES, TRUST DEEDS, CONTRACTS, ETC., (Investments or Loans that are owned to you):
Owner’s Name (Husband/Wife/Joint)
Market Value
Debt
Net Equity
2. NOTES, MORTGAGES, TRUST DEEDS, CONTRACTS, ETC., (Investments or Loans that are owned to you):
Owner’s Name (Husband/Wife/Joint)
Market Value
Debt
Net Equity
3. NOTES, MORTGAGES, TRUST DEEDS, CONTRACTS, ETC., (Investments or Loans that are owned to you):
Owner’s Name (Husband/Wife/Joint)
Market Value
Debt
Net Equity
4. NOTES, MORTGAGES, TRUST DEEDS, CONTRACTS, ETC., (Investments or Loans that are owned to you):
Owner’s Name (Husband/Wife/Joint)
Market Value
Debt
Net Equity
1. BUSINESS INTERESTS*:
Owner’s Name (Husband/Wife/Joint)
Market Value
Debt
Net Equity
2. BUSINESS INTERESTS*:
Owner’s Name (Husband/Wife/Joint)
Market Value
Debt
Net Equity
3. BUSINESS INTERESTS*:
Owner’s Name (Husband/Wife/Joint)
Market Value
Debt
Net Equity
4. BUSINESS INTERESTS*:
Owner’s Name (Husband/Wife/Joint)
Market Value
Debt
Net Equity
*For type of business interest, please use “C” for corporation, “P” for partnership. “LLC” for limited liability company and “SP” for sole proprietorship.

If any business interest is controlled by agreement between parties, please furnish copies of those agreements.
1. SIGNIFICANT ARTICLES OF PERSONAL PROPERTY: Furnishings, Jewelry, Autos, etc
Owner’s Name (Husband/Wife/Joint)
Market Value
Debt
Net Equity
2. SIGNIFICANT ARTICLES OF PERSONAL PROPERTY: Furnishings, Jewelry, Autos, etc
Owner’s Name (Husband/Wife/Joint)
Market Value
Debt
Net Equity
3. SIGNIFICANT ARTICLES OF PERSONAL PROPERTY: Furnishings, Jewelry, Autos, etc
Owner’s Name (Husband/Wife/Joint)
Market Value
Debt
Net Equity
4. SIGNIFICANT ARTICLES OF PERSONAL PROPERTY: Furnishings, Jewelry, Autos, etc
Owner’s Name (Husband/Wife/Joint)
Market Value
Debt
Net Equity
OTHER PROPERTY: Do either you or your spouse own real or personal property jointly with anyone else other than each other (i.e., vacation homes)?
Type of Property
Joint Owner’s Name
Market Value
Debt
Net Equity
Type of Property
Joint Owner’s Name
Market Value
Debt
Net Equity
Type of Property
Joint Owner’s Name
Market Value
Debt
Net Equity
Type of Property
Joint Owner’s Name
Market Value
Debt
Net Equity
Type of Property
Joint Owner’s Name
Market Value
Debt
Net Equity
Type of Property
Joint Owner’s Name
Market Value
Debt
Net Equity
Please use this space or another page to provide additional property information:
1. Real Estate
Total Debt
Total Net Equity
2. Bank Accounts
Total Debt
Total Net Equity
3. Stocks, Bonds, Mutual Funds
Total Debt
Total Net Equity
4. Notes, Mortgages, Trust Deeds, Contracts, Etc.
Total Debt
Total Net Equity
5. Business Interests
Total Debt
Total Net Equity
6. Personal Property
Total Debt
Total Net Equity
7. Other Property
Total Debt
Total Net Equity
8. TOTAL
Total Debt
Total Net Equity
SAFE DEPOSIT BOX: Do you or your spouse have a safe deposit box?
- Yes
- No
Bank:
Branch:
Box Number:
Ownership (Husband/Wife/Joint):
Others listed on Box?
- Yes
- No
If so, Full Name:
Relationship:
Phone #:
Address:
Bank:
Branch:
Box Number:
Ownership (Husband/Wife/Joint):
Others listed on Box?
- Yes
- No
If so, Full Name:
Relationship:
Phone #:
Address:
LIFE INSURANCE:
Please provide the following information:
Name of Insurance Co:
Name of Insurance Co:
Name of Policy Owner:
Name of Policy Owner:
Primary Beneficiary:
Primary Beneficiary:
Alternate Beneficiary(ies):
Alternate Beneficiary(ies):
Face Value (i.e., Policy death benefit value):
Face Value (i.e., Policy death benefit value):
Accumulated Cash Value:
Accumulated Cash Value:
Loans Against Policy:
Loans Against Policy:
Please list any additional life insurance plans
RETIREMENT BENEFIT PLANS:
Please provide the following information regarding any retirement plans (i.e., IRAs, 401(K)s, ESOPs, Pension Plans, Profit-Sharing Plans, Deferred Compensation Plans, etc.) that you may have:
First Benefit Plan
First Benefit Plan (Husband)
First Benefit Plan: Plan Type: Primary Beneficiary: Alternate Beneficiary(ies): Plan Value: Loans Against Plan:
First Benefit Plan (Wife)
First Benefit Plan: Plan Type: Primary Beneficiary: Alternate Beneficiary(ies): Plan Value: Loans Against Plan:
Second Benefit Plan
Second Benefit Plan (Husband)
Second Benefit Plan: Plan Type: Primary Beneficiary: Alternate Beneficiary(ies): Plan Value: Loans Against Plan:
Second Benefit Plan (Wife)
Second Benefit Plan: Plan Type: Primary Beneficiary: Alternate Beneficiary(ies): Plan Value: Loans Against Plan:
Third Benefit Plan
Third Benefit Plan (Husband)
Third Benefit Plan: Plan Type: Primary Beneficiary: Alternate Beneficiary(ies): Plan Value: Loans Against Plan:
Third Benefit Plan (Wife)
Third Benefit Plan: Plan Type: Primary Beneficiary: Alternate Beneficiary(ies): Plan Value: Loans Against Plan:
Please provide any additional information regarding your life insurance policies or retirement benefit plans.
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Intake Form – Husband & Wife

CONFIDENTIAL ESTATE PLANNING QUESTIONNAIRE

Current Marriage

FORMER MARRIAGES:

CHILDREN OF CURRENT MARRIAGE

CHILDREN OF CURRENT MARRIAGE

FAMILY QUESTIONS:

CURRENT ESTATE PLAN:

YOUR ESTATE PLANNIG GOALS:

FIDUCIARIES

Personal Representative (Executor):

Trustee:

Guardian for Children:

Guardian/Conservator:

Attorney-in-Fact:

Health Care Representative:

PROPERTY INFORMATION

LIFE INSURANCE:

RETIREMENT BENEFIT PLANS:

First Benefit Plan

Second Benefit Plan

Third Benefit Plan