ESTATE PLANNING INTAKE FORM
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1 KERNS & SIMS ESTATE PLANNING INTAKE FORM Client Name(s): Date Completed: Referral Source: Page 1 of 13
2 I. Husband Information Social Security No Drivers License No/State How Long State County Facsimile ( ) II. Wife Information Maiden Name Social Security No Drivers License No/State How Long State County Page 2 of 13
3 III. Executor Information SPOUSE (IF CHECKED, SKIP THIS SECTION) IV. Alternate Executor Information V. Health Care Power of Attorney SPOUSE (IF CHECKED, SKIP THIS SECTION) Page 3 of 13
4 VI. Health Care Power of Attorney (ALTERNATE) VII. Health Care Power of Attorney (SECOND ALTERNATE) VIII. Financial Power of Attorney SPOUSE (IF CHECKED, SKIP THIS SECTION) Page 4 of 13
5 IX. Financial Power of Attorney (Alternate) Facsimile ( ) X. BEQUESTS Everything to my Spouse In the event my Spouse predeceases me (or I have no spouse), Everything to my Children In equal shares NOT in equal shares: Per stirpes (if a child predeceases me, their share goes to their children) Per capita (if a child predeceases me, their share gets distributed amongst the other children) In the event my Spouse predeceases me (or I have no spouse), Everything goes to: Per stirpes Per capita Page 5 of 13
6 In addition, I have the following specific bequests: XI. CHILDREN A. Born Issue of This Marriage (Note if Adopted by both parents) B. Born Issue of This Relationship (Prior to Marriage) (Note if adopted) C. Born Issue of Separate Relationship (Note if adopted by relevant party) Page 6 of 13
7 XII. GUARDIAN (Skip if no minor children) XIII. ALTERNATE GUARDIAN (Skip if no minor children) Page 7 of 13
8 XIV. MY ESTATE A. Real Estate Address1 Names on Deed Purchase Price Down Payment Source of Down Payment Outstand. Mortgage 1 Outstand. Mortgage 2 Names on Mortgage Name of Mortgage Co. Appraisal Address2 Names on Deed Purchase Price Down Payment Source of Down Payment Outstand. Mortgage 1 Outstand. Mortgage 2 Names on Mortgage Name of Mortgage Co. Appraisal PLEASE PROVIDE A COPY OF THE DEED IF IN YOUR POSSESSION B. Vehicles Boats Make Model Year Names on Title Purchase Price Outstanding Loan Loan Company Make Model Year Names on Title Purchase Price Outstanding Loan Loan Company Make Model Year Names on Title Purchase Price Outstanding Loan Loan Company Make Model Year Names on Title Purchase Price Outstanding Loan Loan Company PLEASE PROVIDE A COPY OF THE TITLES IF IN YOUR POSSESSION C. Checking Accounts Page 8 of 13
9 D. Savings Accounts E. Stocks Bonds Annuity Other Investment Name of Share Number of Shares of Share Date d Name of Share Number of Shares of Share Date d Name of Share Number of Shares of Share Date d Name of Share Number of Shares of Share Date d F. Retirement Accounts Name of Plans Participant Present Vested? Name of Plans Participant Present Vested? Name of Plans Participant Name of Plans Participant Page 9 of 13
10 Present Vested? Present Vested? G. Life Insurance Accounts Name of Plans Participant Insured Amount Tern or Whole Life? Present Name of Plans Participant Insured Amount Tern or Whole Life? Present H. Household Animal Name of Pet Name of Pet Name of Pet Name of Pet I. Personal Property d in Excess of $500 Asset Asset Asset Asset Asset Asset J. Consumer Debt Obligations Page 10 of 13
11 K. Outstanding Taxes Gov. Entity Debtor Tax Period Gov. Entity Debtor Tax Period Gov. Entity Debtor Tax Period Gov. Entity Debtor Tax Period L. Other Liabilities Lender Purpose Lender Purpose Page 11 of 13
12 Notes Are there any beneficiary designations that you would like to change? Additional Notes: NOTE:**** PLEASE PROVIDE OUR OFFICE WITH COPIES OF ALL PRIOR ESTATE PLANNING MATERIALS, INCLUDING, BUT NOT LIMITED TO, TRUSTS, WILLS, POA, LIVING WILLS, ETC. Page 12 of 13
13 Page 13 of 13
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