estate planning intake form - individual · estate planning intake form - individual created date:...
TRANSCRIPT
Office: 2751 Buford Hwy NE Atlanta, Georgia 30324 Phone: (404) 736-6066 Fax: (404) 736-6057 AtlantaLegalRemedy.com Mailing Address: 2480 Briarcliff Road NE, Suite 6-345, Atlanta, Georgia 30329
ESTATE PLANNING INTAKE QUESTIONNAIRE - INDIVIDUAL
PERSONAL INFORMATION
Zip:
Ext.:
State:
Work Phone:
Email:
Is call needed before fax sent?:
Social Security Number:
Marital Status:
Date of Divorce:
Your Complete Legal Name:
Your Present Address:
City:
Home Phone:
Cell Phone:
Fax:
Date of Birth:
Drivers License Number:
Date of Marriage:
Present Health:
Safe Deposit Box(es) Locations: Name on Box:
Name on Box:
Name on Box:
Other Residences:
Prior Residences:
Today’s Date:
EMPLOYMENT/BUSINESS
Name of Business/Employment:
Business Address:
Phone: Type of Business:
Form of Ownership (sole proprietor, partner, limited partner, corporation, other):
Please complete the following form. If you are unsure what to put or whether a question applies to your situation, you may leave it blank. Additionally, when giving information about a minor, please provide the email and phone number for the child’s guardian instead of the child.
Yes No
Siedentopf Law 1 of 12 Rev.02..18
ESTIMATED INCOME FOR CURRENT YEAR
Base Salary ______________________
Bonus and Other Compensation ______________________
Taxable Dividends and Interest ______________________
Tax-Exempt Income ______________________
Capital Gains or Losses ______________________
Other Income (Specify) ______________________
Total ______________________
MILITARY SERVICE
Your branch of service: ____________________________________
Your dates of service: ____________________________________
Your rank: ____________________________________
Your service number: ____________________________________
Date of discharge: ____________________________________
Your service-connected disabilities (%): ____________________________________
Your pension and retirement information is located: ____________________________________
Name on Account: Account Type: Bank/Institution: Number: Maturity Dates:
Name on Account: Account Type: Bank/Institution: Number: Maturity Dates:
CASH, BANK ACCOUNTS, CERTIFICATES OF DEPOSIT INFORMATION
Account Type:
Number: Maturity Dates:
Account Type:
Name on Account:
Bank/Institution:
Name on Account:
Bank/Institution: Number: Maturity Dates:
Siedentopf Law 2 of 12 Rev.02..18
REAL PROPERTY INFORMATION (Include Residential, Business, Recreational, Rental, Timeshare, Foreign Real Estate, Other)
Type:
Name(s) on Title: Title Held By:
Assessed Value: Insurance:
Type:
Name(s) on Title: Title Held By:
Assessed Value: Insurance:
Type:
Name(s) on Title: Title Held By:
Assessed Value: Insurance:
SECURITIES, STOCKS, BONDS, GOVERNMENT BONDS INFORMATION
Date of Death Value:
Number of Shares:
Certificate Numbers:
Date of Death Value:
Title:
Company Name:
Type of Stock (Common or Preferred):
Title:
Company Name:
Type of Stock (Common or Preferred):
Number of Shares:
Certificate Numbers:
Accrued Interest:
U.S. SAVINGS BONDS
Title:
Date of Issue:
Title:
Date of Issue: Accrued Interest:
Serial Number:
Date of Death Value:
Serial Number:
Date of Death Value:
Serial Number:
Bond Type:
Face Amount:
Date of Issue:
Maturity Date:
Date of Death Value: Face Amount:
BONDS
Title:
Issuer:
Interest Note:
Value at Maturity:
STOCKS
Siedentopf Law 3 of 12 Rev.02..18
TANGIBLE PERSONAL PROPERTY
MOTOR VEHICLES 1 2 3
Make, Model, Year ___________________ ___________________ ___________________ ___________________ Titleholder
___________________ ___________________ ___________________ ___________________
VIN Number Who uses item Loan Company ___________________ ___________________ Loan Balance ___________________ ___________________ Monthly Payments ___________________ ___________________ ___________________ Are Payments Current? ___________________ ___________________ Insurance Coverage ___________________ ___________________
Insurer:
Policy Number:
Insurer:
Policy Number:
Beneficiary:
Amount:
Beneficiary:
Amount:
Serial Number:
Bond Type:
Face Amount:
Title:
Issuer:
Interest Note:
Value at Maturity:
Date of Issue:
Maturity Date:
Date of Death Value: Face Amount:
OTHER VEHICLES (BOATS, TRAILERS, CAMPERS, MOTORBIKES, ETC.)
1 2 3
Make, Model, Year Titleholder VIN Number Who uses item Loan Company Loan Balance Monthly Payments Are Payments Current? Insurance Coverage
INSURANCE AND ANNUITIES
___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________
___________________ ___________________ ___________________ ___________________ ___________________ ___________________
___________________ ___________________
Siedentopf Law 4 of 12 Rev.02..18
___________________
___________________
___________________
___________________
___________________
Current Debts Bank
Loans
Mortgages Payable
Income Taxes
Life Insurance Loans
Other Debts
Total ___________________
Estimated Combined Present Net Worth:
Estimated Value of Estate (including insurance and employment benefits):
Are you currently a beneficiary of an estate or trust? (Includes trusts where you
have an expectancy after a prior interest): Yes No If yes, please state:
Name of Estate/Trust Relationship Value of Your Interest
___________________ ___________________ ___________________ ___________________
___________________ ___________________ ___________________ ___________________
Do you have any expected inheritances from your parents or other relatives?: Yes No
If yes, please state:
Person Who May Leave You Something Relationship Age Value of Your Interest
_________________________ ____________________ ______ _________________________
_________________________ ____________________ ______ _________________________
Personal Effects Home (Principal) Other Real Estate
Non-Market Securities Business Interests Life Insurance
IRAs or Similar Accounts Pension or Profit- Sharing Benefits Other Assets Total
Bank Accounts & Certificates of Deposit
Marketable Securities
LIABILITIES
ASSETS
OTHER ASSETS
___________________
Trustee
Siedentopf Law 5 of 12 Rev.02..18
Are you serving as executor or trustee of any estate or trust?: Yes No If yes, please state:
Estate or Trust Other Trustees Value Attorney Handling
__________________ __________________ __________________ __________________
__________________ __________________ __________________ __________________
Describe any other contingent asset you have been entitled to receive (i.e. negligence recovery):
Relationship:
Zip:
Ext.:
State:
Work Phone:
Email:
Date of Death:
Marital Status:
Name:
Sex:
Present Address:
City:
Home Phone:
Cell Phone:
Date of Birth:
Social Security Number:
Occupation:
Relationship:
Zip:
Ext.:
State:
Work Phone:
Email:
Date of Death:
Marital Status:
Name:
Sex:
Present Address:
City:
Home Phone:
Cell Phone:
Date of Birth:
Social Security Number:
Occupation:
CHILDREN AND STEP-CHILDREN
Siedentopf Law 6 of 12 Rev.02..18
Relationship:
Zip:
Ext.:
State:
Work Phone:
Email:
Date of Death:
Marital Status:
Name:
Sex:
Present Address:
City:
Home Phone:
Cell Phone:
Date of Birth:
Social Security Number:
Occupation:
Relationship:
Zip:
Ext.:
State:
Work Phone:
Email:
Date of Death:
Marital Status:
Name:
Sex:
Present Address:
City:
Home Phone:
Cell Phone:
Date of Birth:
Social Security Number:
Occupation:
Zip: State:
Name:
City:
Date of Birth:
GRAND CHILDREN
Address:
Sex:
Zip: State:
Date of Birth:
Name:
Address:
City:
Sex:
Siedentopf Law 7 of 12 Rev.02..18
Zip: State:
Date of Birth:
Name:
Address:
City:
Sex:
Zip: State:
Date of Birth:
Name:
Address:
City:
Sex:
PARENTS AND OTHER DEPENDENTS
Ante-nuptial or Postnuptial Agreements:
Previous Marriages:
Children of Previous Marriages:
Divorce or Legal Separation:
Settlement Information (child support, etc.):
Special Dependency Cases (handicapped child, relative):
Mental Disability:
Emotional Problems:
Other Health Problems:
INFORMATION FOR LAST WILL AND TESTAMENT
EXECUTOR/EXECUTRIX
Name:
Sex: Relationship:
Present Address:
State: Zip:
Ext.:
City:
Home Phone:
Cell Phone:
Work Phone:
Email:
Siedentopf Law 8 of 12 Rev.02..18
Relationship:
Zip:
Ext.:
ALTERNATE AGENT 2
Name:
Sex:
Present Address:
City:
Home Phone:
Cell Phone:
State:
Work Phone:
Email:
GUARDIAN FOR MINOR CHILDREN
Relationship:
Zip:
Ext.:
Name:
Sex:
Present Address:
City:
Home Phone:
Cell Phone:
State:
Work Phone:
Email:
If above named agent is not available:
ALTERNATE AGENT 1
Name:
If above named agent is not available:
ALTERNATE AGENT 1
Name:
Sex: Relationship:
Zip:
Ext.:
Present Address:
City:
Home Phone:
Cell Phone:
State:
Work Phone:
Email:
Relationship:
Zip:
Ext.:
State:
Work Phone:
Email:
Sex:
Present Address:
City:
Home Phone:
Cell Phone:
Siedentopf Law 9 of 12 Rev.02..18
Relationship:
Zip:
Ext.:
ALTERNATE AGENT 2
Name:
Sex:
Present Address:
City:
Home Phone:
Cell Phone:
State:
Work Phone:
Email:
AGENT UNDER DURABLE POWER OF ATTORNEY
Zip:
Ext.:
Name:
Sex: Relationship:
Present Address:
City:
Home Phone:
Cell Phone:
State:
Work Phone:
Email:
If above named agent is not available:
ALTERNATE AGENT 1
Name:
Sex: Relationship:
Zip:
Ext.:
Present Address:
City:
Home Phone:
Cell Phone:
State:
Work Phone:
Email:
ALTERNATE AGENT 2
Relationship:
Zip:
Ext.:
Name:
Sex:
Present Address:
City:
Home Phone:
Cell Phone:
State:
Work Phone:
Email:
Siedentopf Law 10 of 12 Rev.02..18
HEALTH CARE AGENT
Relationship:
Zip:
Ext.:
Name:
Sex:
Present Address:
City:
Home Phone:
Cell Phone:
State:
Work Phone:
Email:
If above named agent is not available:
ALTERNATE AGENT 1
Name:
Sex: Relationship:
Zip:
Ext.:
Present Address:
City:
Home Phone:
Cell Phone:
State:
Work Phone:
Email:
Relationship:
Zip:
Ext.:
ALTERNATE AGENT 2
Name:
Sex:
Present Address:
City:
Home Phone:
Cell Phone:
State:
Work Phone:
Email:
ACCOUNTANT ATTORNEY
Name: Name:
Firm: Firm:
Address: Address:
Telephone: Telephone:
FAMILY ADVISORS
Siedentopf Law 11 of 12 Rev.02..18
Firm: Firm:
Address: Address:
Telephone: Telephone:
Party Item Approximate Value
________________________ ________________________ ________________________
________________________ ________________________ ________________________
________________________ ________________________ ________________________
________________________ ________________________ ________________________
________________________ ________________________ ________________________
________________________ ________________________ ________________________
________________________ ________________________ ________________________
SPECIFIC BEQUESTS (contained in Last Will & Testament)
WISHES REGARDING DIVISION OF PROPERTY AND ASSETS
I agree to submitting this form via email. I understand that if I do not wish to send via email, I may mail it to: 2480 Briarcliff Road NE,Suite 6-345,Atlanta,Georgia 30329, or call the office at (404)736-6066 to arrange for a secure transfer.
DOCTOR INSURANCE AGENT
Name: Name:
Siedentopf Law 12 of 12 Rev.02..18