Estate Planning Intake ESTATE PLANNING QUESTIONNAIRE We use this questionnaire to get a general understanding of your situation so that we can better advise you on your estate planning needs. Please be as complete as possible when answering this questionnaire. If any of the requested information does not apply or is not readily available, leave those sections blank. Please email us any additional information you would like to provide us. All fields with an * are required. Are you a U.S. Citizen ? YesNo Relationship Status SingleMarriedDivorcedWidowed Date of Marriage Date Finalized Are They a U.S. Citizen ? YesNo DOCUMENTS CURRENTLY EXECUTED OR FILED (Please provide us with a copy) Existing wills. HusbandWife Revocable trusts / Living trusts. HusbandWife Health care power of attorney. HusbandWife Living wills and other medical directives. HusbandWife Property power of attorney. HusbandWife Gift tax returns filed by either spouse. HusbandWife Buy / sell or stock redemption agreements. HusbandWife Other trust instruments. HusbandWife Pre- or postnuptial agreements, separation agreements and divorce decrees. HusbandWife CHILDREN OR OTHER DEPENDENTS (Use full legal name. Use “JT” if both spouses are the parents, “H” if husband is the parent, “W” if wife is the parent, and “A” if the child has been legally adopted - indicating adopted by whom). Name Parent(s) Birth date Relationship (if other dependent) Add More GRANDCHILDREN (Use full legal name and indicate what child of yours is the parent) Name Parent(s) Birth date Add More ADVISORS Attorney Name Telephone Attorney Attorney Attorney Add More EXECUTORS AND TRUSTEES (Please name Executors for your will, and Trustees for your trust, as well as contingent choices) Your Executor Your Trustee Your Spouse’s Executor Your Spouse’s Trustee Primary Choice Contingent Choice INVESTMENT ACCOUNTS TYPE: Money market “MM”, investment “I”, cash management “CM”, or other account that is in a street name (indicate type below). Include securities held by stock brokerage or other institutions. Include securities held by stock brokerage or other institutions. Name of Brokerage Firm Type Acct. Number Owner Amount Add More PERSONAL EFFECTS TYPE:Major personal effects such as motor vehicles, boats, jewelry, club memberships, collections, antiques, furs, household furnishings, and all other valuable nonbusiness personal property (indicate type below and give a lump sum value for miscellaneous, less valuable items). Type Owner Value Add More LIFE INSURANCE, LONG TERM CARE INSURANCE AND ANNUITIES Add Policy OTHER ASSETS TYPE: TYPE: Other property is any property that you have that does not fit into any category, including trusts, investment partnership and limited liability company interests, anticipated inheritances, gifts or lawsuits.. Description Owner Value Add Asset SUMMARY OF VALUES ASSETS AMOUNT Husband Wife Single Cash Accounts Investment Accounts Stocks/Bonds Mortgages, Notes, and other Receivables Business and Professional Interests Personal Effects Retirement Plans Real Property Life Insurance Other Assets Total Assets: LIABILITIES Loans/Accounts payable Contingent liabilities Unpaid taxes Other obligations: Total Liabilities: NET ESTATE • Joint Tenancy (JT), Tenancy in Common (TC) and Community Property (CP) values go ½ in husband’s column, ½ in wife’s column, assuming there is no third party ownership interest. If the other owner is not your spouse, put your interest in jointly held property in the single column. Additional Information 1. Do you or your spouse have a will? If so, please attach a copy of each will. 2. Have you ever lived in a community property state? (Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington or Wisconsin). If so, please name. NoYes 3. Have either you or your spouse been married previously? Please provide a copy of any divorce decree or prenuptial agreement. NoYes 4. Have you made gifts of $10,000 or more to any person (other than your spouse) in any one year? If you have filed a gift tax return, please provide a copy of the most recent return. NoYes 5. If you own joint tenancy property with someone other than your spouse, whose funds were used to purchase the property? MineSomeone Else 6. Estimated inheritance, if any ? 7. Are you or any member of your immediate family a beneficiary or trustee of any trust? NoYes 8. Do you anticipate any business or professional changes in the next 12 months? NoYes 9. Special family needs (support of a parent or child, special education, physical or mental handicap): 10. Do you own any property for your children, such as under a Uniform Transfer to Minor’s Act? NoYes 11.Briefly describe your estate planning goals: 12. Potential Lawsuits (As Plaintif or Defendant) 13.Health Status of Client, Spouse, and/or Parents (Good/Fair/Poor etc.) 14. Mental Health Status (Capacity Issues) CERTIFICATION The undersigned hereby represents to Fox & Moghul, 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. 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:
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