Intake Worksheet - Married

Page 9

9pageborder

ESTATE PLANNING WORKSHEET

FOR SINGLE/DIVORCED/WIDOWED PERSONS

The Law Offices of Susan Gershkoff, Counsellor at Law

Estate Planning & Administration

INSTRUCTIONS FOR COMPLETING THIS WORKSHEET:

• Please make sure all names are spelled correctly, using proper names, not nicknames.

• If you are unsure of a question, simply leave it blank.

• If you have a prior Will or Trust, please bring it with you.

• Please bring copies of the most current deeds (or tax bills) to your real estate, including timeshares and vacant land, whether owned individually, or through any business arrangement.

• Attach extra pages if you need more space.

USING THIS WORKSHEET WILL GREATLY ASSIST US IN DESIGNING AN ESTATE PLAN THAT MEETS YOUR GOALS.

The more you complete, the better your complimentary meeting will be!

TODAY'S DATE: ______

ALL INFORMATION PROVIDED IS STRICTLY CONFIDENTIAL.

IF POSSIBLE, PLEASE RETURN THE COMPLETED WORKSHEET TO US PRIOR TO YOUR APPOINTMENT VIA EMAIL, MAIL OR FAX.

PART ONE: PERSONAL INFORMATION

Full Legal Name

(name most often used to title property and accounts)

Also Known As

(other names used to title property and accounts)

Prefer to be called ______Birth date ______US Citizen? q Y q N

Home Address ______City ______State _____ Zip ______

Home Telephone ______Cell ______Business

County of Residence ______Driver's License No. or Personal Id. Card No.______

Occupation (or prior one, if Retired) ______

Employer______

Email ______q It is okay to communicate with me via my email address.

q Divorced q Widowed q Single

Were you previously married? q Y q N (If you have a divorce agreement, please bring it)

If widowed, full name and date of spouse's death: ______

How is Your Health? q Good q Fair qPoor Please describe any current problems:

______

Are you a prior client? q Y q N

Were you referred to us by anyone? q Y q N If so, by whom? ______

If you have a LEGAL SERVICES PLAN, please state plan name: ______

Plan Member Number OR Last Four Digits of your SSN:______

children and/OR OTHER PRIMARY BENEFICIARIES

Name Gender DOB Relationship

(CIRCLE ONE) (Please Specify: Blood OR Step)

1. ______M F _____/_____/______

Full Address:

______

Marital Status ______Are you concerned with this individual’s ability to manage money? q Y q N

Name Gender DOB Relationship

(CIRCLE ONE) (Please Specify: Blood OR Step)

2. ______M F _____/_____/______

Full Address:

______

Marital Status ______Are you concerned with this individual’s ability to manage money? q Y q N

Name Gender DOB Relationship

(CIRCLE ONE) (Please Specify: Blood OR Step)

3. ______M F _____/_____/______

Full Address:

______

Marital Status ______Are you concerned with this individual’s ability to manage money? q Y q N

Name Gender DOB Relationship

(CIRCLE ONE) (Please Specify: Blood OR Step)

4. ______M F _____/_____/______

Full Address:

______

Marital Status ______Are you concerned with this individual’s ability to manage money? q Y q N

Name Gender DOB Relationship

(CIRCLE ONE)

5. ______M F _____/_____/______

Full Address:

______

Marital Status ______Are you concerned with this individual’s ability to manage money? q Y q N

IF you HAVE CHILDREN: Do they all get along? q Y q N

Do you have any deceased children? q Y q N If so, do they have any surviving children or grandchildren? q Y q N

Names:______

______

Do any of your children have step-children? q Y q N Do you want to exclude any children or grandchildren from receiving any portion of your estate? q Y q N If so, whom?

______

What are your goals in creating or updating your estate plan? (please check all that apply):

q Avoiding Probate or Will Contests q Minimizing Estate Taxes

q Being taken care of if disabled q Making sure loved ones’ inheritance is

q Maximizing loved ones’ inheritance protected from spouses, lawsuits & divorces

q Providing for loved ones q Preserving Privacy

q Avoiding Guardianships q Planning for Business Succession

q Protecting assets from lawsuits or nursing homes q Planning for Pets

q Planning for loved ones with special needs q Planning for Charities

q Peace of mind

q Other: ______

ADVISors: Name Telephone

CPA/Accountant ______

Financial Advisor ______

Business Attorney ______

Life/Long-Term Care Insurance Agent ______

Primary Care Physicians/Specialists ______

______

PART TWO: FINANCIAL INFORMATION

INSTRUCTIONS:

• Please print. Be as specific as you can with regard to account names.

• Account balances will vary, so please just list the approximate balance of each account.

• Watch for REMINDERS regarding papers we would like you to bring in.

real property: Please bring in copies of all Deeds or Tax Bills to Real Estate Owned.

Please list all homes, rental properties, vacation homes, timeshares and vacant land in which you have an interest.

Approx. Market Loan
Full Property Address Original Cost Value Balance

1. $ $ $

2. $ $ $

3. $ $ $

4. $ $ $

5. $ $ $

6. $ $ $

Which #?

Are you planning on selling any of your real estate soon? q Y q N ______

Do any loved ones reside at any of your properties? q Y q N ______

What is the annual cash flow on each rental real estate, if applicable? $ ______

RECREATIONAL VEHICLES- NOT PERSONAL AUTOMOBILES

If you have any large recreational vehicles, such as Boats, Classic or Antique Vehicles, Campers, RVs, or the like, please list them here:

Approx. Market Loan
General Description Owner Value Balance

1. ______$______$______

2. ______$______$______

3. ______$______$______

Bank & Savings accounts

Please do not include any Retirement Accounts, IRAs or 401(k)s here.

Name of Institution Ownership Account Type Approx. Balance

(Checking, Savings, MM, CD)

1. ______q Individual q Joint ______$ ______

2. ______q Individual q Joint ______$ ______

3. ______q Individual q Joint ______$ ______

4. ______q Individual q Joint ______$ ______

5. ______q Individual q Joint ______$ ______

For each joint account, state name(s) of joint account holder(s) and # from above: Name(s) Which #

______

Name(s) Which #

______

Name(s) Which #

______

For any “POD” (payable on death), “TOD” (transfer on death) or “ITF” (in trust for someone) accounts, please state the name(s) of beneficiary and # from above:

Name(s) Which #

______

Name(s) Which #

______

Any UTMA accounts for minors, or the like? q Y q N Which #______

stocks bonds- NOT IN A BROKERAGE ACCOUNT

These include stock certificates or bonds that you actually hold, please list Mutual Funds in the next Section.

Stock or Bond Ownership Number Approx. Market Value

(no. of shares/certificates)

1. ______q Individual q Joint ______$ ______

2. ______q Individual q Joint ______$ ______

3. ______q Individual q Joint ______$ ______

4. ______q Individual q Joint ______$ ______

For each Stock or Bond held jointly, please state the name(s) of joint holder(s) and # from above: Name(s) Which #

______

Name(s) Which #

______

For each POD or TOD Stock or Bond, please state the name(s) of the beneficiary and # from above:

Name(s) Which #

______

Name(s) Which #

______

MUTUAL FUNDS BROKERAGE ACCOUNTs

Please do not include any Retirement, IRAs or 401(k)s here, list them in the next Section.

Name of Firm of Fund/Account Ownership Approx. Market Value

1. ______q Individual q Joint $ ______

2. ______q Individual q Joint $ ______

3. ______q Individual q Joint $ ______

4. ______q Individual q Joint $ ______

5. ______q Individual q Joint $ ______

For each POD or TOD account, please state the name(s) of the beneficiary and # from above:

Name(s) Which #

______

Name(s) Which #

______

IRA ACCOUNTS & COMPANY RETIREMENT PLANS (including qualified annuities)

Custodian of Account Type Account

(Bank, Broker, Employer) (IRA, 401K, 403(b) etc.) Owner Approx. Value

1. ______$______