Preliminary information form

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Before our consultation, we’d like you to complete this information so we can use our time together most efficiently.

• The only info the form requires in order to send it are your name, birth date, and email. Other empty fields will not prevent submission.
• If you have a spouse please be sure to check that box to reveal the relevant fields.

All of the information contained in this form is confidential and protected by Attorney-Client privilege.

Your Name *

First

Last

Your date of birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Are you retired?

• I'm Retired

Do you have a spouse?

havespouse?

• I have a spouse

Spouse's Name

First

Last

Spouse's date of birthMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Is your spouse retired?

• My spouse is retired

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Address

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

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Your email *

Your home phone

Your cell phone

Your occupation

Your work phone

Which number(s) would you prefer to be contacted at

• Home
• Cell
• Work

Is it permissible to communicate with you by email?

• You may use email

Spouse's occupation

Spouse's work phone

Spouse's cell phone

Spouse's email

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How/Where did you hear about us?

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Existing Family Planning

Will

• I have a will
• I do not have a will

Will - spouse

• Spouse has a Will
• Spouse doesn't have a Will

Trust

• I have a Trust
• I do not have a Trust

Trust - spouse

• Spouse has a Trust
• Spouse does not have a Trust

Power of Attorney

• I have a Power of Attorney
• I don't have a Power of Attorney

Power of Attorney - spouse

• Spouse has a Power of Attorney
• Spouse doesn't have a Power of Attorney

Advance Health Care Directive

• I have an Advance Health Care Directive
• I don't have an Advance Health Care Directive

Advance Health Care Directive - spouse

• Spouse has an Advance Health Care Directive
• Spouse doesn't have an Advance Health Care Directive

Long Term Care Insurance

• I have Long Term Care Insurance
• I do not have Long Term Care Insurance

Long Term Care Insurance - spouse

• Spouse has Long Term Care Insurance
• Spouse does not have Long Term Care Insurance

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Your health status plays an important role in the designing of an estate plan best suited for you and your loved ones.

Current health status

• My current health status is good
• My current health status is of concern
• My current health status is uncertain

My health specific concern / problem

Current health status - spouse

• My current health status is good
• My current health status is of concern
• My current health status is uncertain

Spouse's specific concern / problem

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Do you have children?

• I have children
• I do not have children

How many children?

Does your spouse have children?

• Spouse has children
• Spouse does not have children

How many children does your spouse have?

Do you have grandchildren?

• I have grandchildren
• I do not have grandchildren

How many grandchildren?

Does your spouse have grandchildren?

• Spouse has grandchildren
• Spouse does not have grandchildren

How many grandchildren does your spouse have?

Is there anyone in your family with special needs or that requires special consideration?

• Yes, special needs
• No special needs

Special needs comments / concerns

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What do you want your Estate Plan to accomplish?

Is there is anything else about you or your family you would like to tell us?

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Short Financial Information Form™
It is very important you indicate in each category ownership and dollar amount separately, as well as total value.

Monthly income

Your wages

Spouse's wages

Total wages

Your pension

Spouse's pension

Total pension

Your Social Security

Spouse's Social Security

Total Social Security

Your Investments

Spouse's Investments

Total Investments

Your Other

Spouse's Other

Total Other

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Asset Information
In dollar amounts.

Cash, checking, savings, CDs, money market & cash management accounts

Your cash... (alone)

Spouse's (alone)

Joint (community property)

Total

Investment accounts (not including cash) & mutual fund accounts

Yours (alone)

Spouse's (alone)

Joint (community property)

Total

Retirement Accounts: IRA, 401K, 403B, SEP, etc.

Yours (alone)

Spouse's (alone)

Joint (community property)

Total

Life Insurance

Your Death Benefit (alone)

Spouse's Death Benefit (alone)

Joint Death Benefit (community property)

Total Death Benefit

Your Cash Value

Spouse's Cash Value

Joint Cash Value

Total Cash Value

Stocks & Bonds

Your stocks (alone)

Spouse's stocks (alone)

Joint stocks (community property)

Total stocks

Your bonds (alone)

Spouse's bonds (alone)

Joint bonds (community property)

Total bonds

Annuities: Current Value

Your Annuities (alone)

Spouse's Annuities (alone)

Joint Annuities (alone)

Total Annuities (alone)

Real Estate

Your Residence (alone)

Spouse's Residence (alone)

Joint Residence (community property)

Total Residence

Your Other RE

Spouse's Other RE

Joint Other RE

Total Other RE

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Notes/Comments

Submit this form

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