CLIENT INFORMATION

Social Security Number:

Social Security Numbers are required by the Court to file documents

Occupation:

SPOUSE INFORMATION

Full legal name:

Mailing Address:

E-mail Address:

Home telephone number:

Mobile telephone number:

Work telephone number:

Date of Birth:

Social Security Number:

Social Security Numbers are required by the Court to file documents

Have you entered into a premarital agreement?

Yes

Please provide a copy of the signed agreement.

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No

Have either of you been previously married?

Yes

Please provide a copy of the signed agreement.

No

CHILDREN INFORMATION

Child #1:

Yes

Full legal name: Mailing Address: Mobile Telephone Number: Date of Birth: Which of the following best describes the child’s relationship to you?

Naturally born, Adopted, Step-child

If Step-child, Who does the child belong to?

(you or your spouse)

No

Child #2:

Yes

Full legal name: Mailing Address: Mobile Telephone Number: Date of Birth: Which of the following best describes the child’s relationship to you?

Naturally born, Adopted, Step-child

If Step-child, Who does the child belong to?

(you or your spouse)

No

Child #3:

Yes

Full legal name: Mailing Address: Mobile Telephone Number: Date of Birth: Which of the following best describes the child’s relationship to you?

Naturally born, Adopted, Step-child

If Step-child, Who does the child belong to?

(you or your spouse)

No

Child #4:

Yes

Full legal name: Mailing Address: Mobile Telephone Number: Date of Birth: Which of the following best describes the child’s relationship to you?

Naturally born, Adopted, Step-child

If Step-child, Who does the child belong to?

(you or your spouse)

No

Child #5:

Yes

Full legal name: Mailing Address: Mobile Telephone Number: Date of Birth: Which of the following best describes the child’s relationship to you?

Naturally born, Adopted, Step-child

If Step-child, Who does the child belong to?

(you or your spouse)

No

Child #6:

Yes

Full legal name: Mailing Address: Mobile Telephone Number: Date of Birth: Which of the following best describes the child’s relationship to you?

Naturally born, Adopted, Step-child

If Step-child, Who does the child belong to?

(you or your spouse)

No

If any of your children are minors, whom do you wish to designate as guardian if both you and your spouse are deceased?

For each choice, please select "Yes" and complete the requested information. If it's not applicable, please select "No".

First Choice:

Yes

Full Legal Name: Address: E-mail Address: Telephone number: Relationship to you:

No

Second Choice:

Yes

Full Legal Name: Address: E-mail Address: Telephone number: Relationship to you:

No

Do you wish this same individual to be responsible for the financial welfare as well as the personal welfare of the minor children?

If no, then you will need to designate a conservator in the question below. A conservator handles financial matters for the welfare of someone else.

Yes

No

Whom do you wish to designate as conservator if both you and your spouse are deceased?

For each choice, please select "Yes" and complete the requested information. If it's not applicable, please select "No".

First Choice:

Yes

Full Legal Name: Address: E-mail Address: Telephone number: Relationship to you:

No

Second Choice:

Yes

Full Legal Name: Address: E-mail Address: Telephone number: Relationship to you:

No

ASSETS

Real Estate:

Yes

You Only: Spouse Only: Jointly Owned:

No

Investment, Stocks, Bonds, Mutual Funds EXCEPT IRA/401K:

Yes

You Only: Spouse Only: Jointly Owned:

No

Life Insurance:

Yes

Face Amount: Cash Value: You Only: Spouse Only: Jointly Owned:

No

Business Interests:

Yes

You Only: Spouse Only: Jointly Owned:

No

IRA/SEP/401K Retirement Accounts:

Yes

You Only: Spouse Only: Jointly Owned:

No

Household Property EXCEPT jewelry/art:

Yes

You Only: Spouse Only: Jointly Owned:

No

Automobiles or other titled vehicles:

Yes

You Only: Spouse Only: Jointly Owned:

No

Jewelry/Art/Collectibles:

Yes

You Only: Spouse Only: Jointly Owned:

No

Other Property:

Yes

Description: You Only: Spouse Only: Jointly Owned:

No

You Only - TOTAL:

Spouse Only - TOTAL:

Jointly Owned - TOTAL:

LIABILITIES & INDEBTEDNESS

Home Mortgage:

Yes

You?

Yes/No

Spouse?

Yes/No

Joint?

Yes/No

No

Auto Loans:

Yes

You?

Yes/No

Spouse?

Yes/No

Joint?

Yes/No

No

Business Debt:

Yes

You?

Yes/No

Spouse?

Yes/No

Joint?

Yes/No

No

Personal Loans:

Yes

You?

Yes/No

Spouse?

Yes/No

Joint?

Yes/No

No

Other:

Yes

Description: You?

Yes/No

Spouse?

Yes/No

Joint?

Yes/No

No

You - TOTAL:

Spouse - TOTAL:

Joint - TOTAL:

BUSINESS INTERESTS

Name of your business:

Address of business:

Is the business operated as a proprietorship, partnership, or corporation?

Are there any existing partnership agreements, stockholder agreements, employment contracts, options or sales contracts regarding property, private annuities or other documents affecting your business or other assets?

Do you have any special desires as to disposition of business interest to a specific person?

Yes

Full legal name: Address: Telephone number: Relationship to you:

No

WILL INFORMATION

YOU

Who do you wish to appoint as your Personal Representative/Executor?

For each choice, please select "Yes" and complete the requested information. If it's not applicable, please select "No".

First Choice:

Yes

Full Legal Name: Address: E-mail Address: Telephone number: Relationship to you:

No

Second Choice:

Yes

Full Legal Name: Address: E-mail Address: Telephone number: Relationship to you:

No

Are there any persons to be specifically excluded from you Will?

Yes

Please state their full legal name:

No

Are there any beneficiaries who, by reason of health or special need, should receive special consideration in your will?

Yes

Please state their full legal name: Please state the nature of their special need:

No

We may set up a trust within your Last Will and Testament to assist a beneficiary with special needs or for a minor.

Who do you wish to designate as a trustee:

For each choice please select "Yes" and complete the requested information. If it's not applicable, please select "No".

First Choice:

Yes

Full Legal Name: Address: E-mail Address: Telephone number: Relationship to you:

No

Second Choice:

Yes

Full Legal Name: Address: E-mail Address: Telephone number: Relationship to you:

No

Safe deposit Box

Do you have a Safe Deposit box?

Yes

Where is it located? Who has access to the box?

No

Professionals

Do you have an accountant?

Yes

Name: Address: Email Address: Phone Number:

No

Do you have a financial planner?

Yes

Name: Address: Email Address: Phone Number:

No

Where do you intend to keep your signed original Will?

Disposition of your property

Describe below how you would like your estate property to be distributed upon your death if you assume your spouse survives you:

Describe how you would like your estate to be distributed upon your death if you assume that you and your spouse die at the same time or if you are predeceased by your spouse:

SPOUSE

Who do you wish to appoint as your Personal Representative/Executor?

For each choice, please select "Yes" and complete the requested information. If it's not applicable, please select "No".

First Choice:

Yes

Full Legal Name: Address: E-mail Address: Telephone number: Relationship to you:

No

Second Choice:

Yes

Full Legal Name: Address: E-mail Address: Telephone number: Relationship to you:

No

If you wish to designate as a trustee:

For each choice please select "Yes" and complete the requested information. If it's not applicable, please select "No".

First Choice:

Yes

Full Legal Name: Address: E-mail Address: Telephone number: Relationship to you:

No

Second Choice:

Yes

Full Legal Name: Address: E-mail Address: Telephone number: Relationship to you:

No

Are there any persons to be specifically excluded from you Will?

Yes

Please state their full legal name:

No

Are there any beneficiaries who, by reason of health or special need, should receive special consideration in your will?

Yes

Who and why?

No

Are there any beneficiaries who, by reason of health or special need, should receive special consideration in your will?

Yes

Please state their full legal name: Please state the nature of their special need:

No

We may set up a trust within your Last Will and Testament to assist a beneficiary with special needs or for a minor.

Who do you wish to designate as a trustee:

For each choice please select "Yes" and complete the requested information. If it's not applicable, please select "No".

First Choice:

Yes

Full Legal Name: Address: E-mail Address: Telephone number: Relationship to you:

No

Second Choice:

Yes

Full Legal Name: Address: E-mail Address: Telephone number: Relationship to you:

No

Safe deposit box

Do you have a Safe Deposit box?

Yes

Where is it located? Who has access to the box?

No

Professionals

Do you have an accountant?

Yes

Name: Address: Email Address: Phone Number:

No

Do you have a financial planner?

Yes

Name: Address: Email Address: Phone Number:

No

Where do you intend to keep your signed original Will?

Disposition of your property

Describe below how you would like your estate property to be distributed upon your death if you assume your spouse survives you:

Describe how you would like your estate to be distributed upon your death if you assume that you and your spouse die at the same time or if you are predeceased by your spouse:

GENERAL DURABLE POWER OF ATTORNEY

YOU

Who do you wish to appoint as your Power of Attorney?

For each choice, please select "Yes" and complete the requested information. If it's not applicable, please select "No".

First Choice:

No

Yes

Full Legal Name: Address: E-mail Address: Telephone number: Relationship to you:

Second Choice:

Yes

Full Legal Name: Address: E-mail Address: Telephone number: Relationship to you:

No

Do you want this Power of Attorney to be effective immediately or upon your disability?

Immediately

Only upon my disability

SPOUSE

Who do you wish to appoint as your Power of Attorney?

For each choice, please select "Yes" and complete the requested information. If it's not applicable, please select "No".

First Choice:

Yes

Full Legal Name: Address: E-mail Address: Telephone number: Relationship to you:

No

Second Choice:

Yes

Full Legal Name: Address: E-mail Address: Telephone number: Relationship to you:

No

Do you want this Power of Attorney to be effective immediately or upon your disability?

Immediately

Only upon my disability

HEALTH CARE POWER OF ATTORNEY

YOU

Who do you wish to appoint as your Health Care Power of Attorney?

For each choice, please select "Yes" and complete the requested information. If it's not applicable, please select "No".

First Choice:

Yes

Full Legal Name: Address: E-mail Address: Telephone number: Relationship to you:

No

Second Choice:

Yes

Full Legal Name: Address: E-mail Address: Telephone number: Relationship to you:

No

SPOUSE

Who do you wish to appoint as your Health Care Power of Attorney?

For each choice, please select "Yes" and complete the requested information. If it's not applicable, please select "No".

First Choice:

Yes

Full Legal Name: Address: E-mail Address: Telephone number: Relationship to you:

No

Second Choice:

Yes

Full Legal Name: Address: E-mail Address: Telephone number: Relationship to you:

No

PLEASE NOTE

e-acknowledge:

I acknowledge that the information provided above is true and correct to the best of my knowledge.

Please indicate your preferred method of contact (this would include billing):

Telephone:

E-Mail:

e-consent:

I hereby consent to electronic forms of communication such as e-mail.

THANK YOU