Estate Planning Intake Form Using this form will assist us in designing an Estate Plan that mets your goals. All information provided is secure and strictly confidential. Step 1 of 10 10% Part 1: Personal InformationIf you are single, please leave the spouse information blank. Please stay consistent with the same person listed as the client and the same person listed as the spouse.Client's Legal Name(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Middle Last Suffix Name most often used to title property and accounts.Also known as Other names used to title property and accountsPreferred to be called Client's Birth Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SS# US Citizen?(Required) Yes No Home Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone(Required)Secondary PhoneCountry of Residence(Required) Employer(Required) Position Business Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Date of MarriageMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Spouse or Second Grantor's Legal Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Middle Last Suffix Name most often used to title property and accounts.Also known as Other names used to title property and accountsPreferred to be called Spouse's Birth DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SS# US Citizen? Yes No Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary PhoneSecondary PhoneCountry of Residence Employer Position Business Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Children and Other Family MembersUse full legal name. If you need to list more children than spaces provided, please use the comments box at the very end of this form.Child #1 Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Middle Last Suffix Child #1 Date of Birth MM DD YYYY Child #1 Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child #1 Parental SituationPlease choose oneJoint (both spouses are the parents)Client (only the client or first listed grantor is the parent)Spouse (only the spouse or second listed grantor is the parent)Singe (single parent)Child #1 CommentsChild #2 Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Middle Last Suffix Child #2 Date of Birth MM DD YYYY Child #2 Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child #2 Parental SituationPlease choose oneJoint (both spouses are the parents)Client (only the client or first listed grantor is the parent)Spouse (only the spouse or second listed grantor is the parent)Singe (single parent)Child #2 CommentsChild #3 Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Middle Last Suffix Child #3 Date of Birth MM DD YYYY Child #3 Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child #3 Parental SituationPlease choose oneJoint (both spouses are the parents)Client (only the client or first listed grantor is the parent)Spouse (only the spouse or second listed grantor is the parent)Singe (single parent)Child #3 CommentsChild #4 Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Middle Last Suffix Child #4 Date of Birth MM DD YYYY Child #4 Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child #4 Parental SituationPlease choose oneJoint (both spouses are the parents)Client (only the client or first listed grantor is the parent)Spouse (only the spouse or second listed grantor is the parent)Singe (single parent)Child #4 Comments AdvisorsPlease list everyone you can. If you don't have an advisor in a certain area, please leave it blank.Personal Attorney PhoneAccountant PhoneFinancial Advisor PhoneLife Insurance Agent PhoneYour ConcernsCheck the boxes by your primary Estate Plan concerns.Client's Primary Concerns(Required) Desire to get affairs in order and create a comprehensive plan to manage affairs in case of death or disability. Providing for and protecting a spouse. Providing for and protecting children. Providing for and protecting grandchildren. Disinheriting a family member. Providing for charities at the time of death. Plan for the transfer and survival of a family business. Avoiding or reducing your estate taxes. Avoiding probate. Reduce administration costs at time of your death. Avoiding a conservatorship ("living probate") in case of a disability. Avoiding will contests or other disputes upon death. Protecting assets from lawsuits or creditors. Preserving the privacy of affairs in case of disability or at time of death from business competitors, predators, dishonest persons and curiosity seekers. Plan for a child with disabilities or special needs, such as medical or learning disabilities. Protecting children's inheritance from the possibility of failed marriages. Protect children's inheritance in the event of a surviving spouse's remarriage. Provide that your death shall not be unnecessarily prolonged by artificial means or measures. Spouse's Primary Concerns Desire to get affairs in order and create a comprehensive plan to manage affairs in case of death or disability. Providing for and protecting a spouse. Providing for and protecting children. Providing for and protecting grandchildren. Disinheriting a family member. Providing for charities at the time of death. Plan for the transfer and survival of a family business. Avoiding or reducing your estate taxes. Avoiding probate. Reduce administration costs at time of your death. Avoiding a conservatorship ("living probate") in case of a disability. Avoiding will contests or other disputes upon death. Protecting assets from lawsuits or creditors. Preserving the privacy of affairs in case of disability or at time of death from business competitors, predators, dishonest persons and curiosity seekers. Plan for a child with disabilities or special needs, such as medical or learning disabilities. Protecting children's inheritance from the possibility of failed marriages. Protect children's inheritance in the event of a surviving spouse's remarriage. Provide that your death shall not be unnecessarily prolonged by artificial means or measures. Client's Other ConcernsSpouse's Other Concerns Important Family QuestionsPlease select "yes" or "no" for your answer.Are you (or your spouse) receiving social Security, disability, or other governmental benefits? Yes No Are you (or your spouse) making payments pursuant to a divorce or property settlement order? Yes No If yes, please furnish a copy.If married, have you or your spouse signed a pre- or post-marriage contract? Yes No If yes, please furnish a copy.Have you (or your spouse) been widowed? Yes No If a federal estate tax return or a state death tax return was filed, please furnish a copy.Have you (or your spouse) ever filed federal or state gift tax returns? Yes No If yes, please furnish copies of these returns.Do you support any charitable organizations now that you wish to make provisions for at the time of your death? Yes No If so, please explain below.Are there any other charitable organizations that you wish to make provisions for at the time of your death? Yes No If so, please explain below.If married, have you lived in any of the following states while married to each other? Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington or Wisconsin. Yes No Are you (or your spouse) currently the beneficiary of anyone else's trust? Yes No If so, please explain below.Do any of your children have special educational, medical or physcial needs? Yes No Do any of your children receive governmental support or benefits? Yes No Do you provide primary or other major financial support to adult children or others? Yes No Additional information Part 2: Property InformationThis property information checklist helps you list all the property you own and what it is worth. If you do not own property under a particular heading, just leave that section blank. Under certain headings, you may own more property than can be listed on this checklist. If so, please use the comments section at the very end of the form for this information. How you own your property is extremely important for purposes of properly designating and implementing your estate plan. For each property, please indicate how the property is titled.Real PropertyAny interest in real estate including your family residence, vacation home, timeshare, vacant land, etc...General Description and/or Address OwnerPlease choose oneClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedEstimated Market ValueLoan BalanceGeneral Description and/or Address OwnerPlease choose oneClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedEstimated Market ValueLoan BalanceGeneral Description and/or Address OwnerPlease choose oneClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedEstimated Market ValueLoan BalanceFurniture and Personal EffectsList separately only major personal effect such as jewelry, collections, antiques, furs and all other valuable non-business personal property. Give a lump sum value for miscellaneous (less vlauable items)General Description OwnerPlease choose oneClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedEstimated Market ValueGeneral Description OwnerPlease choose oneClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedEstimated Market ValueGeneral Description OwnerPlease choose oneClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedEstimated Market ValueGeneral Description OwnerPlease choose oneClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedEstimated Market Value Automobiles, Boats, and RVsFor each motor vehicle, boat, RV, etc... please list the following: description, how titled, market value and encombrance.General Description General Description General Description General Description Bank AccountsDo not include IRAs or 401(k)s here.Account #1: Name of Institution Account NumberTypePlease choose oneChecking AccountSavings AccountCertificates of DepositMoney MarketOtherOwnerClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedIn client's name for the benefit of a minor (please provide minor's name)In spouse's name for the benefit of a minor (please provide minor's name)Estimated AmountAccount #2: Name of Institution Account NumberTypePlease choose oneChecking AccountSavings AccountCertificates of DepositMoney MarketOtherOwnerClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedIn client's name for the benefit of a minor (please provide minor's name)In spouse's name for the benefit of a minor (please provide minor's name)Estimated AmountAccount #3: Name of Institution Account NumberTypePlease choose oneChecking AccountSavings AccountCertificates of DepositMoney MarketOtherOwnerClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedIn client's name for the benefit of a minor (please provide minor's name)In spouse's name for the benefit of a minor (please provide minor's name)Estimated AmountAccount #4: Name of Institution Account NumberTypePlease choose oneChecking AccountSavings AccountCertificates of DepositMoney MarketOtherOwnerClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedIn client's name for the benefit of a minor (please provide minor's name)In spouse's name for the benefit of a minor (please provide minor's name)Estimated AmountAccount #5: Name of Institution Account NumberTypePlease choose oneChecking AccountSavings AccountCertificates of DepositMoney MarketOtherOwnerClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedIn client's name for the benefit of a minor (please provide minor's name)In spouse's name for the benefit of a minor (please provide minor's name)Estimated AmountAccount #6: Name of Institution Account NumberTypePlease choose oneChecking AccountSavings AccountCertificates of DepositMoney MarketOtherOwnerClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedIn client's name for the benefit of a minor (please provide minor's name)In spouse's name for the benefit of a minor (please provide minor's name)Estimated AmountAccount #7: Name of Institution Account NumberTypePlease choose oneChecking AccountSavings AccountCertificates of DepositMoney MarketOtherOwnerClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedIn client's name for the benefit of a minor (please provide minor's name)In spouse's name for the benefit of a minor (please provide minor's name)Estimated AmountAccount #8: Name of Institution Account NumberTypePlease choose oneChecking AccountSavings AccountCertificates of DepositMoney MarketOtherEstimated AmountOwnerPlease choose oneClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedIn client's name for the benefit of a minor (please provide minor's name)In spouse's name for the benefit of a minor (please provide minor's name)Stocks and BondsList any and all stocks and bonds you own. If held in a brokerage account, lump them together under each account and indicate type below.Account #1: Stocks Bonds or Investment Accounts TypePlease choose oneChecking AccountSavings AccountCertificates of DepositMoney MarketOtherOwnerPlease choose oneClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedIn client's name for the benefit of a minor (please provide minor's name)In spouse's name for the benefit of a minor (please provide minor's name)Estimated AmountAccount #2: Stocks Bonds or Investment Accounts TypePlease choose oneChecking AccountSavings AccountCertificates of DepositMoney MarketOtherOwnerPlease choose oneClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedIn client's name for the benefit of a minor (please provide minor's name)In spouse's name for the benefit of a minor (please provide minor's name)Estimated AmountAccount #3: Stocks Bonds or Investment Accounts TypePlease choose oneChecking AccountSavings AccountCertificates of DepositMoney MarketOtherOwnerPlease choose oneClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedIn client's name for the benefit of a minor (please provide minor's name)In spouse's name for the benefit of a minor (please provide minor's name)Estimated AmountAccount #4: Stocks Bonds or Investment Accounts TypePlease choose oneChecking AccountSavings AccountCertificates of DepositMoney MarketOtherOwnerPlease choose oneClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedIn client's name for the benefit of a minor (please provide minor's name)In spouse's name for the benefit of a minor (please provide minor's name)Estimated AmountAccount #5: Stocks Bonds or Investment Accounts TypePlease choose oneChecking AccountSavings AccountCertificates of DepositMoney MarketOtherOwnerPlease choose oneClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedIn client's name for the benefit of a minor (please provide minor's name)In spouse's name for the benefit of a minor (please provide minor's name)Estimated Amount Life Insurance Policies and AnnunitiesTerm, whole life, split dollar, group life, annuity. Additional Information: Insurance company, type, face amount (death benefit), whose life is insured, who owns the policy, the current beneficiaries, who pays the premium and who is the life insurance agent.Policy InformationRetirement PlansPension, Profit Sharing, H.R. 10, IRA, SEP, 401(K). Additional Information: Describe the type of plan, the plan name, the current value of the plan and any other pertinent informationRetirement Plan InformationBusiness InterestsGeneral and Limited Partnerships, Sole Proprietorships, privately-owned corporations, professional corporations, oil interests, farm and ranch interests. Additional Information: Give a description of the interest, who has the interest, your ownership in the interests and the estimated value of the interests.Business Interest Information Money Owed To YouMortgages of promissory notes payable to you, or other moneys owed to you.Name of Debtor #1 Date of Note Maturity Date Owed to Estimated Current Balance Name of Debtor #2 Date of Note Maturity Date Owed to Estimated Current Balance Anticipated Inheritance, Gift or Lawsuit JudgementGifts or inheritances that you expect to receive at some time int he future; or moneys that you anticipate receiving through a judgement in a lawsuit. Describe in appropriate detail.DescriptionOther AssetsOther property is any property that you have that does not fit into any listed cateogry.Property #1 Type OwnerPlease choose oneClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedIn client's name for the benefit of a minor (please provide minor's name)In spouse's name for the benefit of a minor (please provide minor's name)Estimated Value Property #2 Type OwnerPlease choose oneClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedIn client's name for the benefit of a minor (please provide minor's name)In spouse's name for the benefit of a minor (please provide minor's name)Estimated Value Property #3 Type OwnerPlease choose oneClient only with no other personSpouse only with no other personJoint Tenancy with spouseJoint Tenancy with someone other than spouse (i.e. child, parent, etc..)I cannot determine how the property is ownedIn client's name for the benefit of a minor (please provide minor's name)In spouse's name for the benefit of a minor (please provide minor's name)Estimated Value Part 3: Design InformationPersons to act for you.Guardian for Minor ChildrenIf you have any children under the age of 18, list in order of preference who you wish to be the guardian.Name First Last Relationship Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name First Last Relationship Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Initial Trustee(s)Usually the Maker will be the Trustee of his or her own trust. Often both spouses, jointly, which allows you to continue to jointly control your assets as before.Initial Trustee(s) Client and spouse, if applicable Other Name First Last Relationship Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name First Last Relationship Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Death and Disability TrusteeIn the event of your disability, the trustee will make decisions for you regarding your property and assets if you are unable to make those decisions for yourself. Upon your death, the trustee will carry out your instructions, for distribution to and, if desired, management of property for your beneficiaries. Ideally, you would name two people to serve consecutively.Primary Trustee Name First Last Relationship Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Secondary Trustee Name First Last Relationship Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Power of AttorneyIf you were unable to make financial decisions for yourself, who would you want to make those decisions for you?Primary Power of Attorney First Last Your primary is your spouse unless designated otherwise.Relationship Instructions or Guidelines Secondary Power of Attorney for Client First Last Relationship Instructions or Guidelines Secondary Power of Attorney for Spouse First Last Relationship Instructions or Guidelines Do you want to authorize your Financial Agent to make gifts on your behalf during any period of time you are incapacitated? Client Yes Client No Spouse Yes Spouse No Check all that applyGifting Details Health CareIf you were unable to make financial decisions for yourself, who would you want to make those decisions for you?Primary Power of Attorney First Last Your primary is your spouse unless designated otherwise.Relationship Instructions or Guidelines Secondary Power of Attorney for Client First Last Relationship Instructions or Guidelines Secondary Power of Attorney for Spouse First Last Relationship Instructions or Guidelines Do you want to authorize your Medical Agent to take whatever steps are necessary to keep you in a personal residence rather than nursing home? Client Yes Client No Spouse Yes Spouse No Check all that applyDo you want to provide that upon certification by 2 physicians of need for psychological or substance treatment, Agent may arrange for voluntary admission? Client Yes Client No Spouse Yes Spouse No Check all that applyIn making distributions during any period of time the client is incapacitated, the succcessor Trustee shall give primary consideration to: Disabled spouse, the needs of others. Disabled spouse and other spouse, and then needs of others. Disabled spouse needs and the needs of others equally Remote Contingent BeneficiariesWho do you want to inherit your estate if you and your decendents or the person(s) named in your plan are all deceased. By default, your estate would be distributed to your heirs-at-law as determined by state statute at the time of your death. However, you may name someone else or a charity.Name % amount Name % amount Name % amount Name % amount Additional Comments / Information
