Client Confidential Disclosure
All information is protected by the attorney/client privilege of confidentiality.
Are you doing an estate plan with your spouse?
*
Yes
No
Client 1 Name
*
First Name
Middle Initial
Last Name
Prefer To Be Called
Nickname
Client 1 Date of Birth
 -
Month
 -
Day
Year
Date Picker Icon
Client 1 Social Security Number (optional - if opting out, just enter zeros)
SSN or zeros
Are you a U.S. Citizen?
Yes
No
Are you a veteran?
Yes
No
Employer
Employer
Client 2 Name
First Name
Middle Initial
Last Name
Prefer To Be Called
Nickname
Client 2 Date of Birth
 -
Month
 -
Day
Year
Date Picker Icon
Client 2 Social Security Number (optional - if opting out, please enter X in the field)
SSN or X
Date of Marriage
 -
Month
 -
Day
Year
Date Picker Icon
Do you have a Prenuptial or Marital Property Agreement?
Yes
No
Is your spouse a U.S. Citizen?
Yes
No
Is your spouse a Veteran?
Yes
No
Employer
Employer
Address
Street Address Line 1
Street Address Line 2
City
State
Zip Code
County of Residence
County
Client 1 Home Phone
 -
Area Code
Phone Number
Client 1 Cell Phone
 -
Area Code
Phone Number
Client 2 Home Phone
 -
Area Code
Phone Number
Client 2 Cell Phone
 -
Area Code
Phone Number
Client 1 Email
Client 2 Email
Is it okay to communicate with you via email?
Yes
No
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Your Family
Do you have any children?
*
Yes
No
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Child 1 Name
First Name
Middle Initial
Last Name
Child 1 Date of Birth
 -
Month
 -
Day
Year
Date Picker Icon
Gender
Male
Female
Child of:
Both parents
Client 1 only
Client 2 only
Address
Street Address Line 1
Street Address Line 2
City
State
Zip Code
Home Phone
 -
Area Code
Phone Number
Cell Phone
 -
Area Code
Phone Number
Spouse's name if child is married:
Number of children your child has, if any:
Child 2 Name
First Name
Middle Initial
Last Name
Child 2 Date of Birth
 -
Month
 -
Day
Year
Date Picker Icon
Gender
Male
Female
Child of:
Both parents
Client 1 only
Client 2 only
Address
Street Address Line 1
Street Address Line 2
City
State
Zip Code
Home Phone
 -
Area Code
Phone Number
Cell Phone
 -
Area Code
Phone Number
Spouse's name if child is married:
Number of children your child has, if any:
Child 3 Name
First Name
Middle Initial
Last Name
Child 3 Date of Birth
 -
Month
 -
Day
Year
Date Picker Icon
Gender
Male
Female
Child of:
Both parents
Client 1 only
Client 2 only
Address
Street Address Line 1
Street Address Line 2
City
State
Zip Code
Home Phone
 -
Area Code
Phone Number
Cell Phone
 -
Area Code
Phone Number
Spouse's name if child is married:
Number of children your child has, if any:
Child 4 Name
First Name
Middle Initial
Last Name
Child 4 Date of Birth
 -
Month
 -
Day
Year
Date Picker Icon
Gender
Male
Female
Child of:
Both parents
Client 1 only
Client 2 only
Address
Street Address Line 1
Street Address Line 2
City
State
Zip Code
Home Phone
 -
Area Code
Phone Number
Cell Phone
 -
Area Code
Phone Number
Spouse's name if child is married:
Number of children your child has, if any:
Do you have any other children?
Yes
No
Child 5 Name
First Name
Middle Initial
Last Name
Child 5 Date of Birth
 -
Month
 -
Day
Year
Date Picker Icon
Gender
Male
Female
Child of:
Both parents
Client 1 only
Client 2 only
Address
Street Address Line 1
Street Address Line 2
City
State
Zip Code
Home Phone
 -
Area Code
Phone Number
Cell Phone
 -
Area Code
Phone Number
Spouse's name if child is married:
Number of children your child has, if any:
Child 6 Name
First Name
Middle Initial
Last Name
Child 6 Date of Birth
 -
Month
 -
Day
Year
Date Picker Icon
Gender
Male
Female
Child of:
Both parents
Client 1 only
Client 2 only
Address
Street Address Line 1
Street Address Line 2
City
State
Zip Code
Home Phone
 -
Area Code
Phone Number
Cell Phone
 -
Area Code
Phone Number
Spouse's name if child is married:
Number of children your child has, if any:
Child 7 Name
First Name
Middle Initial
Last Name
Child 7 Date of Birth
 -
Month
 -
Day
Year
Date Picker Icon
Gender
Male
Female
Child of:
Both parents
Client 1 only
Client 2 only
Address
Street Address Line 1
Street Address Line 2
City
State
Zip Code
Home Phone
 -
Area Code
Phone Number
Cell Phone
 -
Area Code
Phone Number
Spouse's name if child is married:
Number of children your child has, if any:
Child 8 Name
First Name
Middle Initial
Last Name
Child 8 Date of Birth
 -
Month
 -
Day
Year
Date Picker Icon
Gender
Male
Female
Child of:
Both parents
Client 1 only
Client 2 only
Address
Street Address Line 1
Street Address Line 2
City
State
Zip Code
Home Phone
 -
Area Code
Phone Number
Cell Phone
 -
Area Code
Phone Number
Spouse's name if child is married:
Number of children your child has, if any:
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Do you have children who predeceased you? If so, please list name(s).
Did that/those child(ren) have any children?
Are any of your children disabled in any way? If so, please list names and identify the disability.
Do any of your children have special education, medical, or physical needs? If so, please explain.
Do you provide primary or major financial support to adult children?
Yes
No
Do any of your children have potential issues with addiction?
Yes
No
Are you concerned with the ability of any children to manage their money?
Yes
No
Are you concerned about your children's ability to get along?
Yes
No
Are you concerned about any of your children being involved in a divorce?
Yes
No
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Other Potential Beneficiaries
Are you considering naming any beneficiaries other than children? If so, please identify the potential beneficiaries and their relationship to you.
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Assets
Real Estate - House, Condo, Land, Vacation Property, etc.
Do you own any real estate?
*
Yes
No
Type of Real Estate
House, Condo, Vacation Property, etc.
How Titled
Individual, Joint Tenants, etc.
Market Value
Lien Amount
Type of Real Estate
House, Condo, Vacation Property, etc.
How Titled
Individual, Joint Tenants, etc.
Market Value
Lien Amount
Type of Real Estate
House, Condo, Vacation Property, etc.
How Titled
Individual, Joint Tenants, etc.
Market Value
Lien Amount
Type of Real Estate
House, Condo, Vacation Property, etc.
How Titled
Individual, Joint Tenants, etc.
Market Value
Lien Amount
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Assets
Bank and Cash Accounts - Savings, Checking, Money Market, CD, etc.
Do you have any bank or cash accounts?
*
Yes
No
Type of Account
Savings
Checking
CD
Money Market
Other
How Titled
Individual, Joint, Trust, etc.
Account Value
Name of Institution
Type of Account
Savings
Checking
CD
Money Market
Other
How Titled
Individual, Joint, Trust, etc.
Account Value
Name of Institution
Type of Account
Savings
Checking
CD
Money Market
Other
How Titled
Individual, Joint, Trust, etc.
Account Value
Name of Institution
Type of Account
Savings
Checking
CD
Money Market
Other
How Titled
Individual, Joint, Trust, etc.
Account Value
Name of Institution
I have arranged for POD/TOD designations on some or all of my bank accounts.
Yes
No
Do you have a safe deposit box?
Yes
No
How Titled
Individual, Joint, Trust, etc.
Institution Name and Location
e.g., BMO Harris in Middleton
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Assets
Investments, Stocks, and Bonds (other than IRAs or retirement plans)
Do you have any investments, stocks, or bonds?
*
Yes
No
Type of Account
Investment
Stocks
Bonds
How Titled
Individual, Joint, Trust, etc.
Account Value
Name of Institution
Type of Account
Investment
Stocks
Bonds
How Titled
Individual, Joint, Trust, etc.
Account Value
Name of Institution
Type of Account
Investment
Stocks
Bonds
How Titled
Individual, Joint, Trust, etc.
Account Value
Name of Institution
Type of Account
Investment
Stocks
Bonds
How Titled
Individual, Joint, Trust, etc.
Account Value
Name of Institution
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Assets
Retirement Accounts - Traditional/Roth IRA, 401(k), 403(b), Pension, etc.
Do you have any retirement accounts?
*
Yes
No
Type of account:
IRA-Traditional
IRA-Roth
401(k)
Pension
Other
How Titled
Individual, Joint, Trust, etc.
Account Value
Institution Name
Named Beneficiaries
Type of account:
IRA-Traditional
IRA-Roth
401(k)
Pension
Other
How Titled
Individual, Joint, Trust, etc.
Account Value
Institution Name
Named Beneficiaries
Type of account:
IRA-Traditional
IRA-Roth
401(k)
Pension
Other
How Titled
Individual, Joint, Trust, etc.
Account Value
Institution Name
Named Beneficiaries
Type of account:
IRA-Traditional
IRA-Roth
401(k)
Pension
Other
How Titled
Individual, Joint, Trust, etc.
Account Value
Institution Name
Named Beneficiaries
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Assets
Life Insurance - Term, Whole/Permanent, etc.
Do you have life insurance?
*
Yes
No
Name of Company
Policy Owner
Named Beneficiaries
Cash Value
$0 for Term Insurance
Death Benefit
Name of Company
Policy Owner
Named Beneficiaries
Cash Value
$0 for Term Insurance
Death Benefit
Name of Company
Policy Owner
Named Beneficiaries
Cash Value
$0 for Term Insurance
Death Benefit
Name of Company
Policy Owner
Named Beneficiaries
Cash Value
$0 for Term Insurance
Death Benefit
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Assets
Annuities
Do you have any annuities?
*
Yes
No
Name of Company
Owner
Value
Named Beneficiaries
Qualified
Non-Qualified
Name of Company
Owner
Value
Named Beneficiaries
Qualified
Non-Qualified
Name of Company
Owner
Value
Named Beneficiaries
Qualified
Non-Qualified
Name of Company
Owner
Value
Named Beneficiaries
Qualified
Non-Qualified
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Motor Vehicles
Year
Make/Model
Color
How Titled
Market Value
Lien Amount
Year
Make/Model
Color
How Titled
Market Value
Lien Amount
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Household Goods & Furniture
Total approximate value of household goods and furniture if you were to sell what you currently own
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Other Financial & Security Interests
Do you have any land contract interests, notes, interests in partnerships or corporations, mortgages owed to you, or business personal property?
*
Yes
No
Type of Interest
Parties to Contract
Date of Contract
Value
Type of Interest
Parties to Contract
Date of Contract
Value
Type of Interest
Parties to Contract
Date of Contract
Value
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Businesses
Do you own a business?
*
Yes
No
Name of Business:
Business address:
Street Address Line 1
Street Address Line 2
City
State
Zip Code
How is your business organized?
Sole Proprietorship
Parntership
LLC
S-Corp
C-Corp
Other
Â
Business Phone Number:
 -
Area Code
Phone Number
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Liabilities
Do you have any liabilities other than those already listed?
*
Yes
No
Creditor
Who is liable?
Lien Amount
Secured
Unsecured
Creditor
Who is liable?
Lien Amount
Secured
Unsecured
Creditor
Who is liable?
Lien Amount
Secured
Unsecured
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Estate Planning Goals
If you are planning with a spouse, consider your goals together.
What are your estate planning goals?
Rows
Very Important
Somewhat Important
Does Not Apply to Me
I want to create a comprehensive estate plan.
I want to control my property while I'm alive and well.
I want to avoid contests and disputes upon my death.
I want to preserve the privacy of my estate from business competitors, creditors, dishonest persons, and curiosity seekers.
I want to avoid probate and minimize settlement expenses for myself and my family.
I want to reduce estate and death taxes to the lowest possible level.
I want my estate plan to be valid in every state if I decide to move.
I want to ensure my estate plan does not render a beneficiary ineligible for government benefits.
I want to give to certain charities.
I want to avoid capital gains tax being paid upon the sale of property.
I have one or more pets that should be protected and cared for.
I recognize the importance of planning with IRAs and retirement plans. I want to minimize the tax deferral growth capability for the benefit of my family.
What are your goals regarding health care?
Rows
Very Important
Somewhat Important
Not Important
Does Not Apply to Me
I want to avoid court control of family assets in the event of my or my spouse's incapacity.
I want to avoid unnecessary placement in a nursing home.
I want my estate to be protected against the costs of extended nursing home care costs.
I want to control which of my family or loved ones will make health care and life support decisions for me if I am incapacitated.
I want my decisions to be followed with respect to feeding tubes and life sustaining procedures.
I want my family to be informed of my health care decisions.
What are your goals for your spouse?
Rows
Very Important
Somewhat Important
Not Important
Does Not Apply to Me
I want my assets to be protected for my spouse in the event a claim is made against my spouse.
I want my assets to be available to support my spouse when I am gone.
I want to ensure my assets pass to my children after my spouse and I are gone, even if my spouse gets remarried.
What are your goals for your children?
Rows
Very Important
Somewhat Important
Not Important
Does Not Apply to Me
I want to appoint guardians for my children rather than let the minor court decide.
I want to plan for a child with special needs.
I want my estate plan to protect the assets of my minor or disabled children.
I want to protect my children's inheritance from the possibility of divorce.
I want to plan for children from a previous marriage so they are treated fairly.
I want to plan for my grandchildren.
I want to provide written directives for my minor children so that my guardian knows how to raise my children.
I want to eliminate the concern that an inheritance left to my child may pass to a spouse, who then remarries, resulting in the disinheritance of my grandchildren.
I want to disinherit one or more children or other family members.
What are your goals for your business?
Rows
Very Important
Somewhat Important
Not Important
Does Not Apply to Me
I want to avoid the risk that my corporation or LLC will fail to protect business assets.
I want to plan the transfer and survival of the family business or farm.
I have other goals for my estate plan not mentioned above, and they are:
My top 3 estate planning goals are:
1. 2. 3.
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Key Advisors and Financial Overview
Financial Advisor(s)
Accountant
Life Insurance Agent
Property Insurance Agent
Household Income:
Under $50,000
$50,000 to $75,000
$75,000 to $100,000
$100,000 to $200,000
$200,000 to $500,000
$500,000 or more
Do any beneficiaries receive Social Security, Disability, or government benefits?
Yes
No
Do you have specific burial requests?
Yes
No
Do you have long term care insurance?
Yes
No
Is there anything else you would like us to know?
Do you have any questions for us?
Submit
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