Client Form

Child One

Name

First Name Last Name

Birth Date

Month Day Year

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number

Last 4 Digits of SS#

Child of this Marriage?

Yes No

Husband's Child?

Yes No

Wife's Child?

Yes No

Marital Status of Child

Name of Spouse of Child

Number of Children of Child

Child Two

Name

First Name Last Name

Birth Date

Month Day Year

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number

Last 4 Digits of SS#

Child of this Marriage?

Yes No

Husband's Child?

Yes No

Wife's Child?

Yes No

Marital Status of Child

Name of Spouse of Child

Number of Children of Child

Child Three

Name

First Name Last Name

Birth Date

Month Day Year

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number

Last 4 Digits of SS#

Child of this Marriage?

Yes No

Husband's Child?

Yes No

Wife's Child?

Yes No

Marital Status of Child

Name of Spouse of Child

Number of Children of Child

Are any of your children or intended beneficiaries physically or mentally challenged?

Yes No

Do any of your children or intended beneficiaries have any special education, medical or financial needs?

Yes No

Do you wish to make any bequests or contributions to charitable organizations? If so, please provide details

If you now support your parents or other relatives, or wish to make provisions for them in your estate plan, please provide the following:

Name

First Name Last Name

Phone Number

Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Relationship

Name

First Name Last Name

Phone Number

Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Relationship

Do you presently have a Will?

Yes No

Living Trust

Yes No

Durable Power of Attorney?

Yes No

Designation of Patient Advocate/Medical Durable Power of Attorney?

Yes No

Is probate avoidance one of your estate plan objectives?

Yes No

Have you ever filed a gift tax return?

Yes No

Provide the following information as to those professionals (if applicable) who advise you.

Accountant:

Full Name

First Name Last Name

Phone Number

Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Investment Counselor/Financial Planner:

Full Name

First Name Last Name

Phone Number

Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Insurance Representative

Full Name

First Name Last Name

Phone Number

Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country