Legacy & Estate Planning Intake

Please complete this intake form prior to your appointment. Fields can be left blank if not applicable - we will review everything together when we meet.

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Please complete and return this intake form prior to your appointment. Fields can be left blank if not applicable - we will review everything together when we meet.

Appointment Date

MM slash DD slash YYYY

If you are completing this form on behalf of someone else, please provide your contact information

Contact Name

Contact Address

Street Address Address Line 2 City State ZIP Code

Contact Email

Contact Phone

Client Information

Same as Contact

Check this box to copy the contact details entered above into the client fields below.

Same as the contact information entered above

Client Name(Required)

Client Address

Street Address Address Line 2 City State ZIP Code

Client Email Address

Client Phone Number

Client Date of Birth

MM slash DD slash YYYY

Client Age

Mental & Physical Health Concerns (Client) - e.g. dementia, high blood pressure, diabetes, etc.

Is the client a veteran?

Yes

Veteran dates of service (if applicable)

Marital Status

Single

Married

Partnered

Divorced

Widowed

# of prior marriages (if any)

Do you have stepchildren or step-grandchildren?

Yes

Are any of your potential beneficiaries disabled?

Yes

Spouse / Partner Information (if applicable)

Spouse / Partner Name

Spouse / Partner Address

Street Address Address Line 2 City State ZIP Code

Spouse / Partner Email Address

Spouse / Partner Phone Number

Spouse / Partner Date of Birth

MM slash DD slash YYYY

Spouse / Partner Age

Mental & Physical Health Concerns (Spouse / Partner)

Is the spouse / partner a veteran?

Yes

Spouse / Partner veteran dates of service (if applicable)

Children - Please list ALL children (even if estranged or not included in the estate plan)

Children

Child's Name

Child's Address

DOB / Age

Marital Status

# of Children & Ages

On Disability? (Y/N)

Asset Information - Real Property

Real Property

Property Type (Home, Mineral Rights, Timeshare, etc.)

Estimated Value

Amount of Mortgage or Lien

# of Acres or Parcels

How and when did you acquire? (Purchase, Gift, Inherit, etc.)

Vehicles

Make/Model (Car, Truck, Boat, RV, or ATV)

Year

Estimated Value

Whose name(s) are on title?

Life Insurance

Life Insurance Policies

Client Insured

Insurance Company

Type (Group, whole, term)

Policy Owner

Death Benefit

Cash Value (if any)

Beneficiary

Other Investments

Include bank accounts, investment accounts, retirement accounts (IRAs, 401ks, TSPs, etc.), annuities, stocks, bonds, gold/silver, cash & cryptocurrency.

Other Investments

Asset Type

Bank or Institution

Estimated Value

Account Owner(s)

Beneficiary (if any)

Your Estate Planning Goals - Concern Level (1=Low, 2=Medium, 3=High)

Privacy regarding my assets and family affairs - Concern Level

1 - Low

2 - Medium

3 - High

Not Applicable

Protect assets from health care or long-term care costs - Concern Level

1 - Low

2 - Medium

3 - High

Not Applicable

Inheritance for my children - Concern Level

1 - Low

2 - Medium

3 - High

Not Applicable

Obtain Medicaid - Concern Level

1 - Low

2 - Medium

3 - High

Not Applicable

Obtain Veteran's benefits - Concern Level

1 - Low

2 - Medium

3 - High

Not Applicable

Protect IRAs for my beneficiaries at my death - Concern Level

1 - Low

2 - Medium

3 - High

Not Applicable

Provide for my pets after my passing - Concern Level

1 - Low

2 - Medium

3 - High

Not Applicable

Other estate planning goals (please describe)

Additional information about your goals

What documents do you currently have?

Do you have a Last Will & Testament?

Yes

Does the Last Will & Testament achieve your goals? If not, why?

Do you have a Durable Power of Attorney?

Yes

Does the Durable Power of Attorney achieve your goals? If not, why?

Do you have a Medical Power of Attorney?

Yes

Does the Medical Power of Attorney achieve your goals? If not, why?

Do you have a Living Will?

Yes

Does the Living Will achieve your goals? If not, why?

Do you have a HIPAA Authorization & Release?

Yes

Does the HIPAA Authorization & Release achieve your goals? If not, why?

Do you have a Revocable Living Trust?

Yes

Does the Revocable Living Trust achieve your goals? If not, why?

Do you have a Irrevocable Trust?

Yes

Does the Irrevocable Trust achieve your goals? If not, why?

Do you have a Retirement Trust?

Yes

Does the Retirement Trust achieve your goals? If not, why?

Who referred you to us?

How else did you hear about us? (Check all that apply)

KDKA Radio

IN Magazine

Friend

Family

Financial Advisor

Seminar or Webinar Attendee

Other

If 'Other', please describe how you heard about us

SPECIAL CONCERNS ADDENDUM
Please complete if you are: retired, may retire soon, have a disability, or have health concerns. Otherwise this section is optional.

Monthly Income - Client

Client - Social Security income/month

Client - Pension income/month

Client - Other income/month

Client - Total monthly income

Monthly Income - Spouse / Partner

Spouse / Partner - Social Security income/month

Spouse / Partner - Pension income/month

Spouse / Partner - Other income/month

Spouse / Partner - Total monthly income

Health Insurance & Long-Term Care Insurance

Client - Medicare Supplement Insurance Provider

Client - Prescription Insurance Provider

Client - Long-term care insurance Provider

Client - Long-term care insurance coverage per day

Spouse - Medicare Supplement Insurance Provider

Spouse - Prescription Insurance Provider

Spouse - Long-term care insurance Provider

Spouse - Long-term care insurance coverage per day

Miscellaneous Issues

Client - Do you currently need help at home from a loved one or professional?

Yes

Spouse - Do you currently need help at home from a loved one or professional?

Yes

Client - Do you expect to need help at home or in a facility in the next 5 years?

Yes

Spouse - Do you expect to need help at home or in a facility in the next 5 years?

Yes

Client - Have you purchased a funeral?

Yes

Spouse - Have you purchased a funeral?

Yes

Client - Have you purchased a burial?

Yes

Spouse - Have you purchased a burial?

Yes

Have you given gifts over $1,000 over the past 5 years? Please describe.

Client signature (typed name)

Date signed

MM slash DD slash YYYY

Legacy & Estate Planning Intake

If you are completing this form on behalf of someone else, please provide your contact information

Client Information

Spouse / Partner Information (if applicable)

Children - Please list ALL children (even if estranged or not included in the estate plan)

Asset Information - Real Property

Vehicles

Life Insurance

Other Investments

Your Estate Planning Goals - Concern Level (1=Low, 2=Medium, 3=High)

What documents do you currently have?

Monthly Income - Client

Monthly Income - Spouse / Partner

Health Insurance & Long-Term Care Insurance

Miscellaneous Issues

Elder Law and Estate Planning Attorneys