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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 ?

    Relationship Status
    Date of Marriage
    Date Finalized


    Are They a U.S. Citizen ?

    DOCUMENTS CURRENTLY EXECUTED OR FILED

    (Please provide us with a copy)

    Existing wills.
    Revocable trusts / Living trusts.
    Health care power of attorney.
    Living wills and other medical directives.
    Property power of attorney.
    Gift tax returns filed by either spouse.
    Buy / sell or stock redemption agreements.
    Other trust instruments.
    Pre- or postnuptial agreements, separation agreements and divorce decrees.
    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)
    GRANDCHILDREN

    (Use full legal name and indicate what child of yours is the parent)

    Name Parent(s) Birth date
    ADVISORS
    Attorney Name Telephone
    Attorney
    Attorney
    Attorney

    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

    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

    LIFE INSURANCE, LONG TERM CARE INSURANCE AND ANNUITIES
























    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

    SUMMARY OF VALUES
    ASSETS
    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.

    3. Have either you or your spouse been married previously? Please provide a copy of
    any divorce decree or prenuptial agreement.

    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.

    5. If you own joint tenancy property with someone other than your spouse, whose funds
    were used to purchase the property?

    6. Estimated inheritance, if any ?

    7. Are you or any member of your immediate family a beneficiary or trustee of any
    trust?


    8. Do you anticipate any business or professional changes in the next 12 months?

    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?

    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: