DIVORCE INFORMATION SHEET
|
|
|
- Leslie Hamilton
- 5 years ago
- Views:
Transcription
1 DIVORCE INFORMATION SHEET Section 1: Your Personal Information Personal Information - Client Client s Name: Have you been known by any other name(s)? Maiden Name (if applicable): Keep Married Name (if applicable): Yes No Place of Birth: Length of residence in this state? Full Name on Birth Certificate: Social Security No: DOB: Driver s License No: Home: Work: Car/Cell: Fax: Religion: Are you pregnant? Yes No N/A Height: Weight: Eyes: Race: Complexion: Military Service / Branch: Employment Employer Name: Phone: How long with current employer? Occupation/Title: Former Occupation (if any): Income Annual Salary (Gross): Salary Deductions Federal: State: Social Security: Insurance: Retirement: Mandatory Retirement Plans: Education Highest Level: Client Referred By: Annual Salary (Net): Health Insurance Medical Dental Vision Individual Coverage Only Family Coverage Union Dues: Date: Health Concerns? Page 1 of 6
2 Section 2: Spouse Personal Information Personal Information - Spouse Spouse s Name: Have you been known by any other name(s)? Maiden Name (if applicable): Keep Married Name (if applicable): Yes No Place of Birth: Length of residence in this state? Full Name on Birth Certificate: Social Security No: DOB: Driver s License No: Home: Work: Car/Cell: Fax: Religion: Are you pregnant? Yes No N/A Height: Weight: Eyes: Race: Complexion: Military Service / Branch: Employment Employer Name: Phone: How long with current employer? Occupation/Title: Former Occupation (if any): Income Annual Salary (Gross): Salary Deductions Federal: State: Social Security: Insurance: Retirement: Mandatory Retirement Plans: Education Highest Level: Annual Salary (Net): Health Insurance Medical Dental Vision Individual Coverage Only Family Coverage Union Dues: Health Concerns? Page 2 of 6
3 Section 3: Marriage Place of Marriage: Grounds for Dissolution: Date of Marriage: Date of Separation: Client How many marriages? How many dissolved? How many by death? Section 4: Allocation of Parental Responsibility Client s Name: Number of Children: Spouse How many marriages? How many dissolved? How many by death? Allocation Desired by Client: Number of Minor Children: Names Ages Sex DOB Adopted Education of Children: Special Problems (Physical, Emotional, Educational, Handicap): Is child receiving public assistance? Yes No If Yes, what is case number? Parenting Time Desired: Additional Concerns: Section 5: Assets Vehicles (# 1) Make: Place of Lien: Name(s) on Title: Primarily driven by: Vehicles (# 2) Make: Place of Lien: Name(s) on Title: Primarily driven by: Year: Current Value: Payment Per Month: Year: Current Value: Payment Per Month: Page 3 of 6
4 Section 5: Assets (continued) Stocks and Bonds Name(s) of Security: Number of Shares: Name(s) on Title: Purchase Date: Household Property Property of Unique or Significant Value: Year Purchased: Bank Accounts (# 1) Name of Bank: Account No: Type of Account: Current Balance: Individual Joint Bank Accounts (# 2) Name of Bank: Account No: Type of Account: Current Balance: Individual Joint Bank Accounts (# 3) Name of Bank: Account No: Type of Account: Current Balance: Individual Joint Life Insurance Policies Insurance Company: Beneficiary: Real Estate (# 1) Address of Property: Address of Lien: Holder of Lien: Real Estate (# 2) Address of Property: Address of Lien: Holder of Lien: Type of Policy: Cash Value: Name of Lien: Name of Lien: Page 4 of 6
5 Section 5: Assets (continued) Jewelry Description: Income Tax Refund / Liability Tax Year: Client s Pension / Profit Sharing Name of Plan: Contributions Since Date of Marriage, if known: Who Purchased: Approximate Value: Amount: Annual Contributions: Spouse s Pension / Profit Sharing Name of Plan: Contributions Since Date of Marriage, if known: Annual Contributions: Inheritance / Gifts Description: How currently held? Date of Receipt: Value: Other Assets Business Interests Name of Company: Type of Business: Type of Ownership: How long in Business: Description of Business Page 5 of 6
6 Section 5: Assets (continued) Liabilities Name of Creditor: Monthly Payment: Gross Amount Due: Type of Purchases: Estate Plan Do you have a will? Please describe estate plan. Have you and your spouse reached any agreements regarding the divorce? If so, explain. Gwendolyn J. Sterk and the Family Law Group, P.C West 183 rd Place, NW Orland Park, IL (815) (815) FAX info@sterkfamilylaw.com sterkfamilylaw.com 2017 Gwendolyn J. Sterk and the Family Law Group, P.C. All Rights Reserved. Page 6 of 6
BROWN, TARLOW, BRIDGES & PALMER, P.C.
BROWN, TARLOW, BRIDGES & PALMER, P.C. DISSOLUTION CLIENT INFORMATION SHEET (Please answer all questions on all pages) Husband's Name: (Father s name, if unmarried) Address: Employer's Name: Employer's
DIVORCE CLIENT INFORMATION SHEET
Consultation Fee Agreement: DIVORCE CLIENT INFORMATION SHEET I understand that there will be a $300.00/hour fee, regardless of whether I decide to take any legal action or not. I also understand that no
FAMILY LAW INTERVIEW FORM
HEIDI H. ROMEO, ESQ. hhromeo@verizon.net BRIAN D. MITCHELL, ESQ. mitchellbriand@yahoo.com MARK S. STAFFORD, ESQ. staffordmarks@yahoo.com LAW OFFICES OF HEIDI ROMEO & ASSOCIATES ATTORNEYS AT LAW 255 West
ESTATE PLANNING INFORMATION FORM
ESTATE PLANNING INFORMATION FORM Please complete this form to the best of your ability. Date: Please bring copies of previous estate planning documents (Will, Trust, Advance Directive, Power of Attorney,
McCleary & Associates, P.C.
McCleary & Associates, P.C. Attorneys at Law G-8161 S. Saginaw Grand Blanc, Michigan 48439 (810) 516-5116 DIVORCE INTAKE INTERVIEW FORM Date Client Full name Birth date Age Birthplace Address Work phone
WILL WORKSHEET. 1. Husband s Name: Social Sec. No. Birthplace: Birth Date: 2. Wife s Name: Social Sec. No. Birthplace: Birth Date:
WILL WORKSHEET I. PERSONAL AND FAMILY INFORMATION (Give full names including middle initial) Your Family: 1. Husband s Name: Social Sec. No. Birthplace: Birth Date: 2. Wife s Name: Social Sec. No. Birthplace:
Wes Linnenbank Attorney at Law
Wes Linnenbank Attorney at Law wes@linnenbanklaw.com P.O. Box 1044 Phone (281)494-6000 Sugar Land, Texas 77487 Fax (281) 494-1021 Date: CLIENT INTERVIEW SHEET Please complete this questionnaire. If you
CLIENT INTAKE FORM I. CLIENT INFORMATION. Maiden Name: Date of Birth: Place of Birth:
CLIENT INTAKE FORM I. CLIENT INFORMATION Name: SS#: Home Address: Home Phone: Cell Phone: Work Phone: Maiden Name: Date of Birth: Place of Birth: E-mail Address: Driver s License #: If you want correspondence
ESTATE PLANNING INFORMATION SHEET I. PERSONAL AND FAMILY INFORMATION
Date: ESTATE PLANNING INFORMATION SHEET I. PERSONAL AND FAMILY INFORMATION Husband s Name: Home Address: (Include County) (First) (Middle) (Last) Telephone: Home Business Occupation: Business Address:
THOMPSON, THOMPSON & GLANVILLE, PLC ATTORNEYS AT LAW
THOMPSON, THOMPSON & GLANVILLE, PLC ATTORNEYS AT LAW www.thompsonglanville.com Tracy M. Thompson Laura H. Thompson Ryan T. Glanville Deborah K. Sherman, Paralegal Date 111 E. Court Street Post Office Box
MILITARY SERVICE: Husband Wife
PERSONAL ESTATE RECORD FAMILY DATA: Husband Full Name Residence Birth Date Birth Place Date of Death S.S. No. Marital Status Wife Children Grandchildren PREVIOUS MARRIAGE(S): Date of Maiden Name Of Spouse
[FORM 6:SS] CALIFORNIA PRACTICE GUIDE: ENFORCING JUDGMENTS AND DEBTS FORMS QUESTIONNAIRE FOR JUDGMENT DEBTOR EXAMINATION. 1. Name of judgment debtor
![[FORM 6:SS] CALIFORNIA PRACTICE GUIDE: ENFORCING JUDGMENTS AND DEBTS FORMS QUESTIONNAIRE FOR JUDGMENT DEBTOR EXAMINATION. 1. Name of judgment debtor](/thumbs/78/78752140.jpg "[FORM 6:SS] CALIFORNIA PRACTICE GUIDE: ENFORCING JUDGMENTS AND DEBTS FORMS QUESTIONNAIRE FOR JUDGMENT DEBTOR EXAMINATION. 1. Name of judgment debtor")
Citation/Title Case Number: [FORM 6:SS] CALIFORNIA PRACTICE GUIDE: ENFORCING JUDGMENTS AND DEBTS FORMS QUESTIONNAIRE FOR JUDGMENT DEBTOR EXAMINATION 1. Name of judgment debtor 2. Address of judgment debtor
INTAKE FORM FOR DIVORCE CASE WITHOUT CHILDREN
DATE: INTAKE FORM FOR DIVORCE CASE WITHOUT CHILDREN The information requested in this form is all required by the court and/or the Kansas Department of Vital Statistics. Please answer all questions as
TRUST SETTLEMENT CLIENT QUESTIONNAIRE INSTRUCTIONS FOR COMPLETING THIS QUESTIONNAIRE
TRUST SETTLEMENT CLIENT QUESTIONNAIRE INSTRUCTIONS FOR COMPLETING THIS QUESTIONNAIRE This TRUST SETTLEMENT CLIENT QUESTIONNAIRE addresses information regarding the Trust Settlement for the Decedent as
Married? Husband's name Wife's name Mailing Address:
DATE COMPLETED: Date of Birth U.S. Citizen? Married? Husband's name Wife's name Mailing Address: email address Date and place of marriage Children Child's Date of Birth Married? Grandchildren Parent Grandchild's
ESTATE PLANNING WORKSHEET for Married Couples
ESTATE PLANNING WORKSHEET for Married Couples Information provided is held in complete confidence, and is used for the sole purpose of analyzing estate planning needs and designing estate planning documents.
JOINT CLIENTS (Please use reverse side or add additional pages if needed) 1. PERSONAL DATA
Date Form Completed: Full Name: Second Client's Name: Customary signature on legal documents: Second client's signature: ESTATE PLANNING INTAKE FORM FOR LAW OFFICES OF PETER W. BULLARD, P.C. 2016 375 East
MEETING INFORMATION FAMILY DATA
MEETING INFORMATION Date: Location: Advisor: Goals For This Meeting: FOR MORE ACCURATE FINANCIAL AND INVESTMENT COUNSEL, PLEASE INCLUDE THE FOLLOWING INFORMATION A copy of your will and related estate
PROBATE QUESTIONNAIRE
PROBATE QUESTIONNAIRE Your full name: First name used: Address: Occupation: Telephone: Home: Work: Fax: E-Mail: How did you find out about our firm? PART 1 INFORMATION ABOUT THE DECEASED Deceased s full
Address. PLEASE PRINT. PLEASE ANSWER ALL QUESTIONS! Do not leave any space or blanks, write NO or N/A where appropriate.
APPLICATION for LOW INCOME HOUSING TAX CREDIT (LIHTC) PROPERTY Project Name Unit # No. of Bedrooms Phone (home) (Cell) (work) Current Address: Email Address PLEASE PRINT. PLEASE ANSWER ALL QUESTIONS! Do
CLARK & BRADSHAW, P.C.
CLARK & BRADSHAW, P.C. 92 North Liberty Street Telephone: (540) 433-2601 ext. 226 Harrisonburg, Virginia 22802 Facsimile: (540) 433-5528 web page: www.clark-bradshaw.com email: valleyelderlaw@clark-bradshaw.com
WILL MAKING CHECKLIST
Level 3 Pivotal Point 50 Marine Parade Southport Qld 4215 07 5557 8785 07 5557 8786 Positive Law Solutions WILL MAKING CHECKLIST Your details Full name Date of birth Occupation Marital status if relevant
. MEMORANDUM OF. (c) My date of birth: (d) My occupation: (e) My birthplace:
. MEMORANDUM OF The following information is meant to assist the executor of my estate and my family in carrying out my burial arrangements upon my death and/or to assist in clearing up all my matters
Client Audit Information Form
Client Audit Information Form Tax Year: The key to good representation is a thorough understanding of your personal situation. Some of these questions may seem very personal, but they are all necessary.
301 PROSPECT STREET BELLINGHAM, WASHINGTON TEL: (360) FAX: (360)
301 PROSPECT STREET BELLINGHAM, WASHINGTON 98225 TEL: (360) 715-3100 FAX: (360) 392-3928 WWW.ESTATEPLANNINGESP.COM Many of my clients find that this Wealth Discovery and Tracking Booklet helps them organize
1199SEIU Greater New York Pension Fund
1199SEIU Greater New York Pension Fund 330 West 42nd Street New York, NY 10036-6977 Tel: (646) 473-8666 Outside NYC area codes: (800) 575-7771 www.1199seiubenefits.org Application for Normal, Early or
ESTATE PLANNING QUESTIONNAIRE
ESTATE PLANNING QUESTIONNAIRE Date Spouse #1 Email Work Phone Cell No. Pager Fax No. Home Phone Spouse #2 Email Work Phone Cell No. Pager Fax No. This form is important. Your accurate and complete responses
APPLICATION FOR HOUSING
APPLICATION FOR HOUSING All applicants must demonstrate a Need, an Ability to Pay a mortgage and a Willingness to Partner. The following information outlines the Home Ownership Program requirements. If
JAMES M. MENNA, P.C Biddle Avenue Wyandotte, Michigan (734) Website:
JAMES M. MENNA, P.C. 3173 Biddle Avenue Wyandotte, Michigan 48192 (734) 281-1705 Email: JMenna@mennalawfirm.com Website: www.mennalawfirm.com *** C O N F I D E N T I A L *** w/ NO CHILDREN TODAY'S DATE:
Instructions on how to complete Enrollment/Change for: I divorced my spouse
Instructions on how to complete Enrollment/Change for: I divorced my spouse 1. Log into the enrollment site at: https://trustmark.benselect.com/enroll Employee ID or SSN PIN: Last 4 of SSN and last 2 of
1199SEIU Home Care Employees Pension Fund
1199SEIU Home Care Employees Pension Fund 330 West 42nd Street New York, NY 10036-6977 Tel: (646) 473-8666 Outside NYC area codes: (800) 575-7771 www.1199seiubenefits.org Application for Normal, Early
ESTATE PLANNING INFORMATION QUESTIONNAIRE (SINGLE PERSON)
ESTATE PLANNING INFORMATION QUESTIONNAIRE (SINGLE PERSON) Date: 1. Personal Information: Full Name: Social Security #: Date of Birth: Place of Birth: Address: Home Phone: Work Phone: Cell Phone: Facsimile:
CONSUMER CREDIT APPLICATION
CONSUMER CREDIT APPLICATION CREDIT REQUEST Which product are you applying for? Personal Loan Term Requested: Overdraft Protection for Account #: Personal Line of Credit Amount Requested: Loan Purpose (check
Pension forecast application form
Please do not tack the documents together Pension forecast application form Pension forecast application I would like to receive a forecast for an old-age pension an invalidity pension a survivors pension
Salary Reduction Contributions Enrollment Form
Salary Reduction Contributions Enrollment Form Employee Information Employer Name Employee Name (Last, First, Middle) Employee Street Address Department - - Social Security Number / to / (mm/dd) Plan Year
PROBATE/POST-MORTEM INTAKE FORM 2016 Foley, Foley & Pearson, P.C.
Foley, Foley & Pearson Use Only: Date: 4300 B Street, Suite 400 Anchorage, AK 99503 T 907 522 2272 / F 907 522 6893 File No.: Attorney: Conflict Check: PROBATE/POST-MORTEM INTAKE FORM 2016 Foley, Foley
COBRA ELECTION NOTICE
COBRA ELECTION NOTICE Date of Notice: DATE NAME ADDRESS CITY STATE ZIP NOTICE OF RIGHT TO ELECT COBRA CONTINUATION COVERAGE This notice contains important information about your right to continue your
Client Information Form - Estate Planning
Client Information Form - Estate Planning Date Personal Data Name (Husband) Home Address (street, city state and zip) Home Phone Occupation Approximate Income Per Year $ Are you now or have you ever been
MODIFICATION REVIEW REQUEST APPLICATION FOR IV-D SERVICES
MODIFICATION REVIEW REQUEST I hereby request that the Friend of the Court conduct a review of the current order for child support in this case. My current child support order is over three (3) years old.
PROBATE INFORMATION SHEET
PROBATE INFORMATION SHEET PERSONAL REPRESENTATIVE Please provide your full legal name as it appears on your driver's license and other IDs Date of birth Social Security number Driver's license or Passport
Turn your land into a legacy
Land As Your Legacy Worksheet Turn your land into a legacy The forms you need to get a plan in place. Please return completed forms to LAYL@nationwide.com or fax to 1-877-351-1143. What s inside: Discovery
Initial Notice Form COBRA Notice Upon Enrollment in a Group Health Plan
Initial Notice Form COBRA Notice Upon Enrollment in a Group Health Plan VERY IMPORTANT NOTICE If a qualifying event occurs that causes you or your spouse or dependent children to lose coverage under group
SECTION 125 PLAN Benefit Election Agreement Plan Year Beginning: January Participant Name (Print)
SECTION 125 PLAN Benefit Election Agreement Plan Year Beginning: January 2012 Participant Name (Print) As an eligible participant in the Muhlenberg College Section 125 Plan, I hereby elect the following
HOLMAN HOWARD & GUECIA ATTORNEYS AT LAW 298 MAIN STREET YARMOUTH, ME 04096
HOLMAN HOWARD & GUECIA ATTORNEYS AT LAW 298 MAIN STREET YARMOUTH, ME 04096 Lewis A. Holman Telephone: (207) 846-6111 John C. Howard Fax: (207) 846-6113 Cecilia J. Guecia Email: holman@holmanhoward.com
ESTATE PLANNING AND WILL INFORMATION FORM
ESTATE PLANNING AND WILL INFORMATION FORM ROLSCH LAW OFFICES 423-3RD AVENUE SE P.O. BOX 189 ROCHESTER, MN 55903 PHONE: (507) 280-1943 FAX: (507) 280-4283 WHEN YOU HAVE COMPLETED THIS FORM, please return
CLIENT QUESTIONNAIRE DISSOLUTION
CLIENT QUESTIONNAIRE DISSOLUTION 3300 Edinborough Way ~ Suite 550 ~ Edina, MN 55435 ~ Phone (952) 405-2000 ~ Fax (952)-405-2001 www.ajwfinancial Client Questionnaire We would greatly appreciate if the
Date: You chose this office because: Referred by a Lawyer/Lawyer s Referred by a Former Client/Friend You are a Former Client Yellow Pages Newspaper
Date: You chose this office because: Referred by a Lawyer/Lawyer s Name: Referred by a Former Client/Friend Name: You are a Former Client Yellow Pages Newspaper Seminar Name: Other: 1. Your full name:
Biographical Record Guide
FUNERAL & CREMATION SERVICES Biographical Record Guide Date: Phone: First Name: Middle Name: Last Name: Residence Address: City: State: Zip: Birth Information Birth Date: Race: City of Birth: State of
Gathering information about your estate
Worksheet 4.3 Section Four: Meeting with Professional Advisers Gathering information about your estate Use this worksheet to take stock of your personal wealth, your family situation, and your current
PERSONAL INFORMATION FORM 2016 Foley, Foley & Pearson, P.C.
Foley, Foley & Pearson Use Only: Date: 4300 B Street, Suite 400 Anchorage, AK 99503 T 907-522-2272 / F 907-522-6893 File No.: Attorney: Conflict Check: PERSONAL INFORMATION FORM 2016 Foley, Foley & Pearson,
Koppel Kessler Julie LLP ESTATE PLANNING QUESTIONNAIRE
ESTATE PLANNING QUESTIONNAIRE I. GENERAL INFORMATION DATE: YOUR FULL NAME: FULL NAME OF YOUR SPOUSE: BIRTH DATE: BIRTH DATE: HOME ADDRESS: TELEPHONE: ( ) E-MAIL YOUR CELL SPOUSE S CELL YOUR BUSINESS ADDRESS:
LAST WILL AND TESTAMENT QUESTIONNAIRE
LAST WILL AND TESTAMENT QUESTIONNAIRE Date created: - - Potential Client Information Name of Client DOB Client Address County of Residence Current Age Phone: (H) (C) Email: Does the Potential Client have
AFFORDABLE HOUSING APPLICATION
For Office Use-Check all that apply TAX CREDIT *BOND *HUD *OTHER *Requires Addendum Property: Annandale Park Marketing Source Apartment # Unit Type: Move-in Date App Fee Lease Term Rental Rate Securit
PROBATE ESTATE ADMINISTRATION CHECKLIST
PROBATE ESTATE ADMINISTRATION CHECKLIST The purpose of this Probate Questionnaire is to 1) help prepare you for our upcoming estate settlement consultation; 2) provide us with important personal and asset
FREQUENTLY ASKED QUESTIONS (FAQ s) AB 205, Domestic Partner Legislation GENERAL INFORMATION
FREQUENTLY ASKED QUESTIONS (FAQ s) AB 205, Domestic Partner Legislation GENERAL INFORMATION When does CalPERS require a copy of the certificate or registration of domestic partnership to qualify for a
Community Planning and Economic Development Homebuyer Down Payment Grant Program
Community Planning and Economic Development Homebuyer Down Payment Grant Program This application is for use in determining eligibility for Down Payment Assistance Program. You must have been pre-approved
Health Care Election Form
Health Care Election Form The open enrollment period is the month of vember with an effective date of January 1 st the following year. You may also change coverage if you experience a qualifying event.
ESTATE PLANNING INFORMATION (MARRIED)
Law Offices of Brian J. Cohan, P.C. 69 RFD Long Grove, IL 6007 Licensed in Illinois www.brianjcohanlawoffices.com E-mail: brian@brianjcohanlawoffices.com (87) 0- Main (87) 09-70 Emergency (87) 89-7 Fax
FINANCIAL WELLNESS. Your Financial and Personal Information Document
FINANCIAL WELLNESS Your Financial and Personal Information Document Sharsheret 2013 Your Personal Financial IQ Can you answer the following questions? Where do you keep your important financial documents?
VASILIADIS PAPPAS ASSOCIATES LLC 2551 Baglyos Circle, Suite A-14 Bethlehem, PA Phone: (610) Fax: (610)
VASILIADIS PAPPAS ASSOCIATES LLC 2551 Baglyos Circle, Suite A-14 Bethlehem, PA 18020 Phone: (610) 694-9455 Fax: (610) 694-9829 www.lawvp.com PERSONAL PROFILE I. PERSONAL INFORMATION 1. Client name: (Last)
Request for Group Coverage/Enrollment Form
Employee Benefit Trust 1205 Windham Parkway Romeoville, IL 60446 800.807.9460 / 630.378.3005 fax Request for Group Coverage/Enrollment Form Due to the Health Insurance Portability and Accountability Act
DOUGLAS W. LEWIS ATTORNEY AT LAW
DOUGLAS W. LEWIS ATTORNEY AT LAW Telephone: 770-682-3765 260 Constitution Boulevard Facsimile: 770-995-7215 Lawrenceville, GA 30046 dwlewislaw@yahoo.com www.dwlewislaw.com WIFE S INFORMATION DIVORCE QUESTIONNAIRE
Benefits Enrollment - Life Event Rules and Requirements. When is the change effective? Change is effective on the date of birth.
Benefits Enrollment - Life Event Rules and Requirements You can make changes to your medical plan, coverage level or election during the year if you qualify for a Special Enrollment under HIPAA (Health
ESTATE PLANNING INTAKE QUESTIONNAIRE
Cathy R. Cook Ethan J. Arenstein Attorneys at Law Scott M. Brooks, Paralegal 114 East Eighth Street, Cincinnati, Ohio 45202 Elizabeth J. Byrd, Legal Assistant Phone: 513.241.4029 Fax: 513.723.8634 ESTATE
CLIENT INFORMATION ORGANIZER ESTATE ADMINISTRATION
CLIENT INFORMATION ORGANIZER ESTATE ADMINISTRATION ESTATE PLANNING and ADMINISTRATION Eight 3rd Street North, Suite 507 Davidson Building P.O. Box 1484 Great Falls, Montana 59403 (406) 727-2200 or (406)
Social Security Number Driver s License Number Visa or Mastercard No. Home Phone. Occupation Name of Employer No. of Years Salary Business Phone $ per
To: American Airlines Federal Credit Union Member Name: Address: Date of Birth: ZIP Code: CHECK AS APPLICABLE Applicant is applying for this loan: o Individually, without a co-signer or guaranty of a person
Funeral Aid Insurance: Benefit claim form
Funeral Aid Insurance: Benefit claim form Name of scheme Code Important: This form must be completed by the Employer when a claim for an insured s or a family members funeral aid benefit is submitted.
Medical: Premium Quality Value HSA MEC NONE. Dental: Premium Quality NONE
ENROLLMENT / CHANGE FORM Addition Change Termination Reason: Effective Date If change or termination, complete only Employee s Name, Social Security Number, and the Change details. Termination date includes
Loss of Spouse Checklist
Armstrong Wealth Management Group Reginald A. T. Armstrong, CPWA President 1807 West Evans St., Suite A Florence, SC 29501 843-292-9997 armstrongwealth@lpl.com armstrongwealth.com Loss of Spouse Checklist
Healthcare Participation Section MMC Draft NA
March 17, 2009 Healthcare Participation Section MMC Draft NA Note to Reviewers: No notes at this time Date May 1, 2009 Participating in Healthcare Benefits MMC Participating in Healthcare Benefits This
ESTATE PLANNING QUESTIONNAIRE. Date of Birth: Legal Name of Child Address Date of Birth SS#: # of Children
DATE: _ ESTATE PLANNING QUESTIONNAIRE I. FAMILY AND OCCUPATIONAL DATA: Date of Birth: Address: Citizenship: SS#: Telephone # Home: Work: Cell: Email: Occupation: Name of Employer: Business Address: Date
ESTATE PLANNING QUESTIONNAIRE (SINGLE INDIVIDUAL)
ESTATE PLANNING QUESTIONNAIRE (SINGLE INDIVIDUAL) Thank you for considering Estate Planning & Elder Law Services, P.C. to assist you with the preparation of your estate planning documents. To maximize
LAW OFFICES OF FLOOD & FAVATA ESTATE PLANNING QUESTIONNAIRE
Today s Date: DOB: / / SSN: - - Name: Address: Home Phone: Cell: County of Residence: U.S. Citizen: Yes No If no, citizen of Employer: Retirement Date: Veteran: Yes No Spouse: DOB: / / SSN: - - U.S. Citizen:
AFFILIATES OFFICERS AND EMPLOYEES PENSION FUND Service Employees International Union, CTW, CLC PENSION APPLICATION
SECTION 2 SECTION 1 AFFILIATES OFFICERS AND EMPLOYEES PENSION FUND Service Employees International Union, CTW, CLC 1800 MASSACHUSETTS AVE., NW, SUITE 301 WASHINGTON, DC 20036 (202) 730-7500 or (800) 458-1010
Taxpayer Questionnaire
Personal Information Select Filing Status (select ONE) Single Married Filing Joint Married Filing Separately Head of Household Qualifying Widow(er). Year spouse died: Help Me Choose Enter Personal Information
COBRA Continuation Coverage
COBRA Continuation Coverage The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), is a federal law that requires plans to offer a temporary extension of benefits to employees and eligible
RAYMOND JAMES TRUST ESTATE PLANNING ASSESSMENT
RAYMOND JAMES TRUST ESTATE PLANNING ASSESSMENT At Raymond James Trust, we are committed to helping clients develop meaningful and comprehensive estate plans that meet their overall financial objectives.
2019 Employee Benefits Guide
BENEFIT ELIGIBLE STATUTORY EMPLOYEES Benefit Effective Date January 1, 2019 2019 Employee Benefits Guide All Employees must complete an Election Form Changes, no changes and coverage waivers. Annual Notices
ESTATE PLANNING WORKSHEET
+ ESTATE PLANNING WORKSHEET THE FIRST STEP TOWARD PREPARING APPROPRIATE ESTATE PLANNING DOCUMENTS SUCH AS WILLS, POWERS OF ATTORNEY AND LIVING WILLS IS TO THOROUGHLY REVIEW YOUR CIRCUMSTANCES, NEEDS AND
ESTATE PLANNING QUESTIONNAIRE
ESTATE PLANNING QUESTIONNAIRE Date No. E-mail address File Number Business Phone No. Fax No. This form is extremely important. Your accuracy and completeness in responding will help me best represent you.
HOENE & WORRELL PROBATE INFORMATION FORM. Decedent s Full Name. Decedent s Maiden Name or previous legal names. Place of Birth (city & state)
DECEDENT INFORMATION HOENE & WORRELL PROBATE INFORMATION FORM Decedent s Full Name Decedent s Maiden Name or previous legal names Social Sec. No. Date of Birth County of Residence Date of Death Place of
Johnson, Larson & Peterson, P.A. Attorneys at Law
Estate Planning and Will Information Form When you have completed this form, please return it to our office or bring it along to your scheduled office conference. We rely upon the information you provide
BENEFIT APPLICATION INSTRUCTIONS PART A. PERSONAL DATA SOCIAL SECURITY NUMBER NAME (LAST) FIRST MIDDLE STREET ADDRESS CITY STATE ZIP CODE
L a b o r e r s A n n u i t y P l a n f o r N o r t h e r n C a l i f o r n i a 220 Campus Lane, Fairfield, CA 94534-1498 Telephone: (707) 864-2800 Toll Free: 1-(800) 244-4530 A. Read each question carefully
HIPAA Special Enrollment Rights
Provided by Clarke & Company Benefits, LLC HIPAA Special Enrollment Rights Group health plans often provide eligible employees with two regular opportunities to elect health coverage an initial enrollment
70 Hatfield Lane Goshen, New York SSN: First Name: MI: Last Name: Employment: Employed Unemployed Retired Employer: Employer Address:
70 Hatfield Lane Goshen, New York 10924 SSN: First Name: MI: Last Name: Prefix (Ms., Mr.,) Sex: M F DOB: Marital Status: Single Married Divorced Widowed Spouse Name: Employment: Employed Unemployed Retired
ESTATE PLANNING FACT SHEET. Full Name: Primary Occupation: Address (Include Country): Business Address: Electronic Mail Address:
Date: ESTATE PLANNING FACT SHEET CM#: I. Full Primary Occupation: Address (Include Country): Business Electronic Mail Telephone: Home: Business: Cell: Birthdate: U.S. Citizen: Yes No If No, Country: Single
RETIREMENT LIVING APPLICATION
RETIREMENT LIVING APPLICATION (PLEASE USE BLACK OR BLUE INK WHEN COMPLETING THIS FORM) APPLICANT PERSONAL INFORMATION Applicant s last name: First: Middle: Mr Miss Mrs Ms Marital Status (circle one): Single
FRANCHISE QUALIFICATION REPORT
Primo Franchising, Inc 610 Ryan Avenue, Building V-4 Westville, NJ 08093 PH: 856-742-1999 Fax: 856-742-5000 Revised 1/25/2017 PERSONAL INFORMATION Date: FRANCHISE QUALIFICATION REPORT Name: Email: Address:
Law Offices of Mark E. Lewis & Associates Toll Free (800)
Law Offices of Mark E. Lewis & Associates Toll Free (800)832-2580 Trust & Will Preliminary Information Packet Client: M F Date of Birth: / / US Citizen? Yes No Address: City/State/Zip COUNTY of Residence:
Occupation: Cell: Date and Place of Marriage: Have you or your spouse been married before?
ESTATE PLANNING QUESTIONNAIRE Client 1: Date of Birth: Home Address: Date: SSN: - - Employer: Occupation: Phone No.: Cell: Email: Are You a U.S. Citizen: Client 2: Date of Birth: Cell: Email: SSN: - -
ESTATE PLANNING INFORMATION
ESTATE PLANNING INFORMATION Thank you for contacting us about estate planning. This data sheet can be helpful for organizing your thoughts about estate planning and for providing information to us about
Office Use Only Application Type: Bedroom Size: Application Date: Alias(es)
Rental Application (Please Print) Name of Head of Household Office Use Only Application Type: Bedroom Size: Application Date: Name of Spouse or Co- Head of Household Applicants Address City, State, & Zip
HIPAA Special Enrollment Rights
Provided by Brown & Brown of Louisiana, LLC HIPAA Special Enrollment Rights Group health plans often provide eligible employees with two regular opportunities to elect health coverage an initial enrollment
FAMILY DATA. Name (First, Middle Initial, Last) Street Address City State Zip. Home Phone # Cell Phone # Sex Date of Birth
PAGE 1 FAMILY DATA Marital Status: Single Married Divorced Widower/Widow Wedding Anniversary: CLIENT INFORMATION Name (First, Middle Initial, Last) Age Street Address City State Zip Home Phone # Cell Phone
SENTRY PROPERTY MANAGEMENT, INC North Broad Street Colmar, PA PHONE: 215/ or 717/ FAX: 215/
SENTRY PROPERTY MANAGEMENT, INC. 2312 North Broad Street Colmar, PA 18915 PHONE: 215/822-9729 or 717/391-7739 FAX: 215/822-0502 DATE: APPLICANT S NAME(S): PROPERTY: Park Manor Apartments APARTMENT NUMBER:
PATRICIA A. LEONG. Attorney at Law certified specialist in estate planning & probate law ESTATE PLANNING GUIDE
PATRICIA A. LEON Attorney at Law certified specialist in estate planning & probate law ESTATE PLANNIN UIDE 3180 CROW CANYON PLACE, SUITE 250 SAN RAMON, CALIFORNIA 94583 TELEPHONE (925) 830-0684 FACSIMILE
WILL PREPARATION DOCUMENT
WILL PREPARATION DOCUMENT Just a few simple questions. QualitySolicitors Changing the way you see lawyers This Will Planner is to help you prepare for questions the solicitor will ask at your appointment.
ESTATE PLANNING WORKSHEET
ESTATE PLANNING WORKSHEET Information provided is held in complete confidence, and is used for the sole purpose of analyzing estate planning needs and designing estate planning documents. Preparation of
SSN Birth Date / / Spouse s Name: Legal Address: City State Zip Country. Mailing (or secondary) Address: City State Zip Country
Client Profile Form Establish a new client Update an existing client* * All sections required for new client relationships. For client updates, please complete the applicable sections only. The signature
About Your Benefits 1
About Your Benefits 1 BENEFIT HIGHLIGHTS Your Benefits Provide Immediate Eligibility for You and Your Family As a full-time employee, you are eligible for coverage under most benefit plans, including Health