Couples Estate Planning Intake Form

CLIENT INFORMATION

[Strictly Confidential]

Husband’s Legal Name:

Other Names used by Husband:

Address:

County:

E-Mail:

Telephone: (home)

(Work)

(Cell)

Date of Birth:

Social Security No.

US citizen?
Yes
No

Business/Employment:

Wife's Legal Name:

Other Names used by Wife:

Telephone: (home)

(Work)

(Cell)

Date of Birth:

Social Security No.

Business/Employment:

US citizen?
Yes
No

Prior Marriages?

Husband:
Yes
No

How Terminated?
Death
Divorce

Date

Wife:
Yes
No

How Terminated?
Death
Divorce

Date

Children of this marriage:

Children
Yes
No

Number of grandchildren:

Range of Ages:

Children from prior marriage:

Child Name
Age
Spouse
- H
- W

Treat all children as if they were the children of this marriage?
Yes
No

Any deceased children?
Yes
No

Any adopted children?
Yes
No

BURIAL WISHES

Husband:

At my death, I wish to be:
Cremated
Buried.

If cremation, I would like my ashes disposed as follows:

If buried, I would like my remains interred as follows:

I have already made arrangements at:

Wife:

At my death, I wish to be:
Cremated
Buried.

If cremation, I would like my ashes disposed as follows:

If buried, I would like my remains interred as follows:

I have already made arrangements at:

ESTIMATED* VALUE OF ESTATE

* Use best guess; this can be a “ballpark” estimate.
** Do not show benefits which will terminate at death (e.g., pension, social security, etc.).
Value of Life Insurance policies will be listed separately on the next page.

TYPE OF ASSET:

REAL ESTATE
(fair market value, less loans)

HUSBAND'S
SEP. PROP.

$

WIFE'S
SEP. PROP.

$

COMMUNITY
PROPERTY

$

SECURITIES:
(stocks, bonds, mutual funds)

$

CASH TYPE ASSETS:
(cash, annuities, notes due you)

$

BUSINESS INTERESTS:
(sole proprietorship, partnerships, closely held corporation, etc.)

$

RETIREMENT PLANS:
(IRA, 401k, etc.**)

$

VEHICLES:
(autos, R.V., boat)

$

PERSONAL PROPERTY:
(jewelry, furniture, antiques)

$

TOTAL

$

LIFE INSURANCE

(do not include accidental death policies)

"Insured" will be "H" husband; "W" wife; or "S" survivor
"Owner" will be "C" community property; "H" husband or "W" wife
"Cash Value" use best estimate (term policies normally have no cash value)
"Face Value" is the amount payable at death
"Beneficiary" will be "H" husband; "W" wife; "C" child, "O" other

INSURED

(H/W/S)

OWNER

(H/W/C)

CASH VALUE

($ estimate) $

FACE VALUE

Date:

Husband's Signature

Wife's Signature

Intake Form Couple

CLIENT INFORMATION

Prior Marriages?

Children of this marriage:

Children from prior marriage:

MORE QUESTIONS

BURIAL WISHES

ESTIMATED* VALUE OF ESTATE

TYPE OF ASSET:

HUSBAND'S
SEP. PROP.

WIFE'S
SEP. PROP.

COMMUNITY
PROPERTY

LIFE INSURANCE

INSURED

OWNER

CASH VALUE

FACE VALUE

BENEFICIARY

INSURED 2

INSURED 3

INSURED 4

INSURED 5

INSURED 6

WAIVER OF POTENTIAL CONFLICT OF INTEREST

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Intake Form Couple

CLIENT INFORMATION

Prior Marriages?

Children of this marriage:

Children from prior marriage:

MORE QUESTIONS

BURIAL WISHES

ESTIMATED* VALUE OF ESTATE

TYPE OF ASSET:

HUSBAND'S SEP. PROP.

WIFE'S SEP. PROP.

COMMUNITY PROPERTY

LIFE INSURANCE

INSURED

OWNER

CASH VALUE

FACE VALUE

BENEFICIARY

INSURED 2

INSURED 3

INSURED 4

INSURED 5

INSURED 6

WAIVER OF POTENTIAL CONFLICT OF INTEREST

HUSBAND'S
SEP. PROP.

WIFE'S
SEP. PROP.

COMMUNITY
PROPERTY