Intake Form – Spouse or Partner – Robert Carlson

Confidential Estate Planning Intake Form & Personal and Confidential
Client Info: Last Name
First Name:
Middle Name
Mr/Mrs/Dr/Other:
Other/Former name(s):
Date of Birth:
Social Security No:
Street Address or PO Box:
Street Address City State / Province / Region ZIP / Postal Code Country
Home Phone:
Cell Phone:
Email Address:
Employer :
Occupation/Position:
Annual Salary :
Business Phone:
Other Monthly Income:
Pension:
Rental:
Rental:
Disability:
Disability:
Investment:
Investment:
Are you making payment pursuant to a divorce or property settlement?
- Self
- Spouse
- N/A
Have you ever had a will or a trust? Will or Trust :
- Yes (Will)
- No (Will)
- Yes (Trust)
- No (Trust)
If you marked YES under TRUST, Please provide the full legal name of trust and date of creation:
First Last
What is your current health status?
- Excellent
- Good
- Poor
Any Specific health concerns/issues?
Are you a US Citizen?
- Yes
- No
Are you a disabled Veteran?
- Yes
- No
Who referred you to Me?
Spouse/Partner Information (If Applicable)
First Middle Last
Mr/Mrs/Dr/Other:
Other/Former name(s):
Date of Birth:
Social Security No:
Street Address or PO Box:
Street Address City State / Province / Region ZIP / Postal Code Country
Home Phone:
Cell Phone:
Email Address:
Employer :
Occupation/Position:
Annual Salary :
Business Phone:
Other Monthly Income:
Pension:
Rental:
Rental:
Disability:
Disability:
Investment:
Investment::
Do you have a prenuptial agreement?
- Yes
- No
Are you making payments pursuant to a divorce or property settlement?
- Self
- Spouse
- N/A
Have you ever had a will or Trust?
- Yes
- No
- Yes
- No
What is your current health status?
- Excellent
- Good
- Poor
Any Specific health concerns/issues?
Are you a US Citizen?
- Yes
- No
Are you a disabled Veteran?
- Yes
- No
To assist with creating your estate plan, please answer the following questions.

Please note there are no right or wrong answers – only your answers:

Identify any of the following issues that are important to you with an “X”
Minimize Gift and Estate Taxes
- Client
- Spouse/Partner
Provide for Disabled Descendants
- Client
- Spouse/Partner
Eliminate Probate or Guardianship
- Client
- Spouse/Partner
Protect Children/Grandchildren from Divorce and Creditors
- Client
- Spouse/Partner
Provide for Children
- Client
- Spouse/Partner
Protect children from immature spending Habits
- Client
- Spouse/Partner
Provide for grand children
- Client
- Spouse/Partner
Protect Children’s inheritance in the Event of Subsequent Remarriage by the Survivor
- Client
- Spouse/Partner
Plan for a Disability
- Client
- Spouse/Partner
Pass Values and Responsibility to Family Members
- Client
- Spouse/Partner
What is your goal in meeting with me?
What is your most important financial goal?
What do you see as the major threat to your personal goals?
Do you have any family dynamics that may affect your estate planning?
Are you or your spouse taking a trip out of the state or out of the country in the next 12 months?
- Yes
- No
- Maybe
Family Information
Previous Marriage(s) by Client (include previous spouse’s Names, Date of Marriage, or Date of Death)
Previous Marriage(s) by Spouse/Partner (include Previous Spouse’s Names, Date of Marriage, or Date of Death)
Living Children (On the “Child of:” line indicate if child is(J)) Joint, (H) Husband’s, (W) Wife’s, or (P) Partner’s Child.)
1. Full Name:
DOB:
Child of:
Adopted(Y/N):
Gender:
Current Address:
2. Full Name:
DOB:
Child of:
Adopted(Y/N):
Gender:
Current Address:
3. Full Name:
DOB:
Child of:
Adopted(Y/N):
Gender:
Current Address:
4. Full Name:
DOB:
Child of:
Adopted(Y/N):
Gender:
Current Address:
5. Full Name:
DOB:
Child of:
Adopted(Y/N):
Gender:
Current Address:
Deceased Children (On the “Child of” line indicate if Child is (J) Joint, (H) Husband’s, (W) Wife’s, or (P) Partner’s Child.)
Name
Birth Date
Date of Death
Male/Female
Child of
Name
Birth Date
Date of Death
Male/Female
Child of
Name
Birth Date
Date of Death
Male/Female
Child of
Are you or your Spouse/Partner pregnant or anticipating becoming pregnant in the near future?
- Yes
- No
Have you or your Spouse/Partner ever had a child born outside of marriage?
- Yes
- No
Have you or your Spouse/Partner ever had a child given up for adoption or for which parental rights have been terminated?
- Yes
- No
Family Information (Continued)

Grandchildren
Name
Birth Date
Parent’s Names
Male/Female
Adopted(Y/N)
- Yes
- No
Name
Birth Date
Parent’s Names
Male/Female
Adopted(Y/N)
- Yes
- No
Name
Birth Date
Parent’s Names
Male/Female
Adopted(Y/N)
- Yes
- No
Name
Birth Date
Parent’s Names
Male/Female
Adopted(Y/N)
- Yes
- No
Name
Birth Date
Parent’s Names
Male/Female
Adopted(Y/N)
- Yes
- No
Client’s Parents
Client’s Parents
Relation
Select One Name
- Living
- Deceased
Spouse/Partner’s Parents
Relation
Select One Name
- Living
- Deceased
Client’s Parents
Relation
Select One Name
- Living
- Deceased
Spouse/Partner’s Parents
Relation
Select One Name
- Living
- Deceased
Client’s Parents
Relation
Select One Name
- Living
- Deceased
Spouse/Partner’s Parents
Relation
Select One Name
- Living
- Deceased
Client’s Parents
Relation
Select One Name
- Living
- Deceased
Spouse/Partner’s Parents
Relation
Select One Name
- Living
- Deceased
Client’s Siblings
Client’s Siblings
Relation
Select One Name
- Living
- Deceased
Spouse/Partner’s Siblings
Relation
Select One Name
- Living
- Deceased
Client’s Siblings
Relation
Select One Name
- Living
- Deceased
Spouse/Partner’s Siblings
Relation
Select One Name
- Living
- Deceased
Client’s Siblings
Relation
Select One Name
- Living
- Deceased
Spouse/Partner’s Siblings
Relation
Select One Name
- Living
- Deceased
Have any of the named people ever had a child given up for adoption or for which parental rights have beenterminated?
- Yes
- No
Does anyone in your immediate family have any special educational, medical, or physical needs?
- Yes
- No
If Yes, please explain:
Other than with your minor children (if applicable), do you foresee a time when someone may be dependent on you?
- Yes
- No
If Yes, please explain:
Real Property
Include your personal residence(s), investment property, vacation homes (excluding time shares), vacant land, mineral interests, etc. If you have a copy of your legal description or deed, please attach a copy to this form.
Type (residence, rental, vacant land etc.)
Address & County:
Owner(s):
Current Value: $
Outstanding Mortgage?
- Yes
- No
Type (residence, rental, vacant land etc.)
Address & County:
Owner(s):
Current Value: $
Outstanding Mortgage?
- Yes
- No
Type (residence, rental, vacant land etc.)
Address & County:
Owner(s):
Current Value: $
Outstanding Mortgage?
- Yes
- No
Type (residence, rental, vacant land etc.)
Address & County:
Owner(s):
Current Value: $
Outstanding Mortgage?
- Yes
- No
Bank Accounts and Investment Accounts
Please do not list retirement account in this section such as: IRAs, 401Ks, Roth IRAs, SEPs, etc.
Name of Bank/Institution:
Account type:
Account Number:
Name on Account:
Balance: $
Advisor Name:
Name of Bank/Institution:
Account type:
Account Number:
Name on Account:
Balance: $
Advisor Name:
Name of Bank/Institution:
Account type:
Account Number:
Name on Account:
Balance: $
Advisor Name:
Do you have any Safe Deposit Boxes?
- Yes
- No
If yes, what is the Box Number?
Name of Institution
Name(s) on Box
Retirements Accounts
Please list your IRAs, 401Ks, SEPs, Profit Sharing, Thrift Savings, etc
Name of Institution
Name(s) on Accounts
Account type
Account Number
Balance: $
Current Beneficiaries
Advisor
Name of Institution
Name(s) on Accounts
Account type
Account Number
Balance: $
Current Beneficiaries
Advisor
Name of Institution
Name(s) on Accounts
Account type
Account Number
Balance: $
Current Beneficiaries
Advisor
Life Insurance Policies
Life Insurance Policies 1 (fill the details in the below box)
Life Insurance Company : Policy Number: Owner of Policy : Insured: Current Beneficiaries : Death Benefit: Type of Policy : Agent Name:
Life Insurance Policies 2 (fill the details in the below box)
Life Insurance Company : Policy Number: Owner of Policy : Insured: Current Beneficiaries : Death Benefit: Type of Policy : Agent Name:
Life Insurance Policies 3 (fill the details in the below box)
Life Insurance Company : Policy Number: Owner of Policy : Insured: Current Beneficiaries : Death Benefit: Type of Policy : Agent Name:
Disability Insurance:
Do you currently have disability insurance?
- Yes
- No
Insurance Provider :
Policy No:
Information for Business Owners
Do you own a business? (if no please proceed to the next section)
- Yes
- No
Name of Business :
Address of Business :
Phone Number :
Tax identification Number of Business :
How is your business currently being taxed?
- C-Corp
- S-Corp
- Partnership
- Sole Proprietorship
Owner/Member/Shareholder
Percentage
Units/Shares
Owner/Member/Shareholder
Percentage
Units/Shares
Owner/Member/Shareholder
Percentage
Units/Shares
Please indicate if your business already has in place one of the following:
- Operating Agreement
- Corporate Minutes
- Bylaws
- Buy-Sell Agreement
Other
your retirement, incapacitation or Death?
- Yes
- No
Has your business been valuated?
- Yes
- No
Current Value of your Business? $
Do you have whole or part ownership in another/other Business
- Yes
- No
Other Information or Businesses:
Advisors
Financial Planner:
Financial Planner: Company : Address: Phone: E-mail:
Client(s) authorize(s) me to contact their financial planner?
- Yes
- No
Accountant
Accountant: Company : Address: Phone: E-mail:
Client(s) authorize(s) me to contact their Accountant?
- Yes
- No
Life Insurance Agent
Life Insurance Agent: Company : Address: Phone: E-mail:
Client(s) authorize(s) me to contact their Life Insurance Agent?
- Yes
- No
Client(s) authorize(s) me to contact their Life Insurance Agent?
- Yes
- No
Attorney
Attorney: Company : Address: Phone: E-mail:
Client(s) authorize(s) me to contact their Attorney?
- Yes
- No
Funeral Home
Funeral Home: Company : Address: Phone: E-mail:
Client(s) authorize(s) me to contact their Funeral Home?
- Yes
- No
Trust Information
Preferred Name of Trust:
The Successor trustee takes over control of your trust after you or your original trustee can no longer serve as trustee. When your estate plan involves a revocable trust, you and/or Your Spouse/Partner usually serve as the initial Trustees. The Successor Trustee can be an individual, more than one individual, or a corporate entity (such as a bank or a trust company.)
Successor Trustee details
First Choice: Second Choice: Third Choice: Special Instructions:
Guardian for Minor Children (If Applicable)
Please list the individual(s) who should be responsible for the care and control of your children in the event you are incapacitated or deceased.
Guardian for Minor Children (If Applicable): Client’ s Choice
First Choice: Second Choice: Third Choice: Special Instructions:
Guardian for Minor Children (If Applicable): Spouse/Partner’s Choice (If Applicable)
First Choice: Second Choice: Third Choice: Special Instructions:
Personal Representative
Your Personal Representative will liquidate and administer your probate estate if necessary, your Personal Representative may be the same person or entity that you have named as your Successor Trustee
Personal Representative: Client’ s Choice
First Choice: Second Choice: Third Choice: Special Instructions:
Personal Representative: Spouse/Partner’s Choice (If Applicable)
First Choice: Second Choice: Third Choice: Special Instructions:
Durable Power of Attorney
A Durable Power of Attorney is an individual who serves as an Attorney-in-Fact and is authorized to act on your behalf in a limited or general financial capacity. Your Attorney-in-Fact’s powers may be effective immediately or they may become effective only upon your incapacitation.
Durable Power of Attorney : Client’ s Choice
First Choice: Address: Telephone No: Second Choice: Address: Telephone No: Third Choice: Address: Telephone No:
Durable Power of Attorney: Spouse/Partner’s Choice (If Applicable)
First Choice: Address: Telephone No: Second Choice: Address: Telephone No: Third Choice: Address: Telephone No:
Should your Attorney-in Fact have the right to immediately exercise these Powers?
- Yes
- No
Special Instructions:
Healthcare Power of Attorney
A Healthcare Power of Attorney is an individual you select as an agent to make decisions in regard to your medical care should you become incapacitated.
Healthcare Power of Attorney : Client’ s Choice
First Choice: Address: Telephone No: Second Choice: Address: Telephone No: Third Choice: Address: Telephone No:
Healthcare Power of Attorney: Spouse/Partner’s Choice (If Applicable)
First Choice: Address: Telephone No: Second Choice: Address: Telephone No: Third Choice: Address: Telephone No:
Special Instructions:
If you are at the end of your life or in a terminal condition, do you wish to be on life support?
- Yes
- No
Do you wish to be buried or cremated?
- Buried
- Cremated
Does your spouse wish to be buried or cremated?
- Buried
- Cremated
Client: Do you want to be an organ donor?
- Yes
- No
Spouse: Do you want to be an organ donor?
- Yes
- No
HIPAA Agent
The individual(s) you appoint as your HIPAA Agent will immediately have full access to any and all of your medical records. Please list the individuals to be named as Authorized Recipients under the Health Insurance Portability and Accountability Act (HIPAA).
HIPAA: Client’ s Choice
Agent Name: Address: Telephone No: Agent Name: Address: Telephone No: Agent Name: Address: Telephone No
HIPAA: Spouse/Partner’s Choice (If Applicable)
Agent Name: Address: Telephone No: Agent Name: Address: Telephone No: Agent Name: Address: Telephone No
Notes, Distribution of Personal Property, and Supplemental Information
CAPTCHA

Intake Form – Spouse or Partner

Confidential Estate Planning Intake Form & Personal and Confidential

To assist with creating your estate plan, please answer the following questions.

Please note there are no right or wrong answers – only your answers:

Identify any of the following issues that are important to you with an “X”

Family Information

Living Children (On the “Child of:” line indicate if child is(J)) Joint, (H) Husband’s, (W) Wife’s, or (P) Partner’s Child.)

Deceased Children (On the “Child of” line indicate if Child is (J) Joint, (H) Husband’s, (W) Wife’s, or (P) Partner’s Child.)

Family Information (Continued)

Real Property

Bank Accounts and Investment Accounts

Retirements Accounts

Life Insurance Policies

Disability Insurance:

Information for Business Owners

Advisors

Trust Information

Guardian for Minor Children (If Applicable)

Personal Representative

Durable Power of Attorney

Healthcare Power of Attorney

HIPAA Agent