Form 1. Intake Form – Single Person - Robert Carlson

Date:
MM slash DD slash YYYY
Full Name:
Date of Birth
MM slash DD slash YYYY
Tell:
Email:
Address:
Please state any particular circumstances that prompted you to make an estate plan now (consider lifetime care for pets or other animals):
Please list any special concerns such as life-threatening medical issues or disabilities:
Please prepare the following documents:
- Will
- Power of Attorney
- Living Will
- Health Care Proxy
- Living Trust
- Ladybird Deed
- other
Other Documents
Do you have a Funeral Contract
- Yes
- No
Do you plan to make a Medicaid application?
- Yes
- No
If so, what are the circumstances?
Interment*
- Burial
- Cremation
If cremation, where will your ashes be preserved or disposed?
Instructions for a memorial service:
Disposition of personal property:*
- Instructions in Will?
- Memorandum with Will?
Disposition of personal property:
Names(s), relationship(s) & address(es) of Personal Representative(s)(formerly executor/executrix):
Names(s), relationship(s), address(es) and telephone numbers of person(s) designated for your power of attorney & successive power of attorney:
Names(s), relationship to you, address and telephone number of Health Care Proxy(ies)
Names(s), relationship to you, address and telephone number of Guardians for minor children:
Children or Heirs:
Name:
Date of Birth
MM slash DD slash YYYY
Address:
Married?*
- Yes
- No
Children?*
- Yes
- No
Divorced?*
- Yes
- No
Name:
Date of Birth
MM slash DD slash YYYY
Address:
Married?
- Yes
- No
Children?
- Yes
- No
Divorced?
- Yes
- No
Name:
Date of Birth
MM slash DD slash YYYY
Address:
Married?
- Yes
- No
Children?
- Yes
- No
Divorced?
- Yes
- No
Are any children or grandchildren adopted, divorced or separated, physically or mentally handicapped or require special consideration?
- Yes
- No
If yes, please explain:
ASSET INFORMATION– NOTE: THERE IS NO FEDERAL ESTATE TAX FOR ESTATES UNDER $5,490,000 (THE “UNIFIED CREDIT”) FOR ANY PERSON DYING IN 2018. THERE STATE IS NO TAX ON THE ESTATE OF A FLORIDA RESIDENT.

Individually, Homestead and Jointly-Owned Property

Please list your assets. Below is a list of separate categories to assist you:

A. Real Estate Assets
1. Residence
Date of Purchase
MM slash DD slash YYYY
Mortgage
Value
Owned jointly?
- Yes
- No
2. Commercial real estate
Date of Purchase
MM slash DD slash YYYY
Mortgage
Value
Owned jointly?
- Yes
- No
3. Other
Date of Purchase
MM slash DD slash YYYY
Mortgage
Value
Owned jointly?
- Yes
- No
B. Checking Account:
Do you have a Pay on Death (POD) designation?
- Yes
- No
Bank Name & Address:
Account No.
Owned jointly?
- Yes
- No
C. Savings Account: :
Do you have a Pay on Death (POD) designation?
- Yes
- No
Bank Name & Address:
Account No.
Owned jointly?
- Yes
- No
D. Certificates of Deposit, Treasury Bills, Money Market Funds, etc.
Do you have a Pay on Death (POD) designation?
- Yes
- No
Institution Name:
Address:
Account No.
Owned jointly?
- Yes
- No
H. Automobiles(s)
Make
Model
Year
Purchase Price
Current Value
Outstanding Loan
Make
Model
Year
Purchase Price
Current Value
Outstanding Loan
J. Other important personal assets:
Value
$
L. Pension Plan/IRA, etc.
Type
Name of Plan
Plan administrator name:
Address:
Do you have a Pay on Death (POD) designation for your IRA?
- Yes
- No
Cemetery lots: Owner/proprietor name:
Location:
Telephone contact:
Jointly Owned Property:
Joint owner’s name
Joint owner’s address (street)
(City/town)
State
Zip Code
Joint owner’s telephone number
Joint owner’s interest:
Amount of acquisition price contributed by client as joint owner:
Amount of acquisition price contributed by client as joint owner:
Amount of acquisition price contributed by client as joint owner:
Life Insurance: Company:
Agent’s name, address & tel. #:
Type Policy:
Policy No.
Amount of Coverage $
Cash Value (if any) $
Life Insurance Beneficiary(ies):
Name(s)
Address(es)
Share of death benefit: %
Name(s)
Address(es)
Share of death benefit: %
Name(s)
Address(es)
Share of death benefit: %
Liabilities, potential creditor problems?
- Yes
- No
If so, please describe:
Do you want your estate plan to include a provision to hold any share of the assets in trust for either a child or a grandchild?
- Yes
- No
If so, please state how you want this provision to operate and why you are including this provision:
Name of beneficiary
Dollar amount or % to be held back:
Dollar amount or % to be held back:
Name of beneficiary
Dollar amount or % to be held back:
Dollar amount or % to be held back:
Are you concerned about Medicaid asset protection?
- Yes
- No
If so, please explain your reasons & goal(s) for such protection:
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