MARGOLIS & BLOOM, LLP CLIENT INFORMATION FORM Today's Date:

Transcription

1 MARGOLIS & BLOOM, LLP CLIENT INFORMATION FORM Today's Date: _ Name: _ Year of Birth Address: Day Phone: Eve. Phone: County of Residence: U.S. Citizen: Yes No If no, citizen of Employer: Retirement Date: Veteran: Yes No Spouse: Year of Birth Citizen: Yes No If no, citizen of Employer: Retirement Date: Veteran: Yes No If spouse is deceased, date of death: / / FAMILY Date of Marriage: / / Children: _

2 Concerns and goals of consultation: Have you or your spouse been married before? If yes, do you or your spouse have any children from this previous marriage? Do you or your spouse have children who have died leaving children? Does anyone to whom you may be leaving part of your estate require any help or protection in managing money or other property? Do you and your spouse have a pre-nuptial or post-nuptial agreement? MEDICAL/DISABILITY Is anyone in your family disabled or seriously ill? If yes, please explain: Has anyone in your family recently entered a hospital or skilled nursing facility? If so, which facility? HEALTH INSURANCE Please check if you have: Medicare You Spouse Insurance from Employer You Spouse Medicare Supplement You Spouse Long-Term Care Insurance You Spouse Other You Spouse - 2 -

3 FINANCIAL Income Producing Assets: Such as bank accounts, Brokerage Accounts, Stocks, Corporate or U.S. Bonds, IRAs, Annuities, Other Financial Institution and Account Type Approximate Value In Whose Name? TOTAL: Have you or your spouse made any transfers or gifts of $10,000 or more during the past five years? Real Estate: Approximate In Whose Name Purchase Price Description of Property Value Name? (If Known) Are any of the above properties not connected to a sewer line? Do you or your spouse have an interest in any business? Approximate Monthly Income: You Your Spouse Joint Social Security Employment Pension from Other TOTALS: Which sources of income have a benefit for a surviving spouse? - 3 -

4 Life Insurance: Whose Life? Company Face Value Cash Value Beneficiary Do you or your spouse expect an inheritance? Are you or your spouse the beneficiary of any trust? Liabilities: (mortgages, notes to banks, notes to others, loans on insurance, other) Description Balance Due Monthly Expenses Health insurance premium Medical Expenses Real estate taxes Homeowner s insurance premium Condominium Fee Rent Do you pay for heat and utilities? Yes No LEGAL Please check if you have: Last Will and Testament You Spouse Durable Power of Attorney You Spouse Living Will/Health Care Proxy You Spouse Living Trust You Spouse Location of important papers: - 4 -

5 Please bring copies of the following documents with you to your meeting if you have them: 1. Will, Codicil, Trust Agreements 2. Real Estate Deeds, Appraisals 3. Admission Agreements to hospitals and health facilities 4. Guardianship documents 5. Living Will, Health Care Declaration or Power of Attorney, Durable Powers of Attorney 6. A list of full names, addresses, telephone numbers of people who have a part in your planning as executors, trustees, beneficiaries of your estate, helpers, and advisors 7. Retirement plans, including any forms designating beneficiaries - 5 -