Personal and Family Information Form

Personal and Family Information Form
PART 1

PERSONAL INFORMATION
Client Legal Name
First NameLast Name
Also Known As
(other names used to title property and accounts)
Prefer to be called
Birth date
MonthDayYear
US Citizen?
YESNO
Home Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Home Telephone
Please enter a valid phone number.
Business Telephone
Please enter a valid phone number.
County of Residence
Employer
Position
Business Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
E-mail Address
example@example.com
It is okay to communicate with me via my E-mail address.

CHILDREN AND OTHER FAMILY MEMBERS
Name Birth date Parent or Relationship Comments
1
2
3
4
5

ADVISORS
Personal Attorney
First NameLast Name
Telephone
Accountant
First NameLast Name
Telephone
Financial Advisor
First NameLast Name
Telephone
Life Insurance Agent
First NameLast Name
Telephone
Your Concerns
Please rate the following as to how important they are to you:
(H high concern, S some concerned, L low concern, N/A no concern or not applicable)

	Level of Concern
Desire to get affairs in order and create a comprehensive plan to manage affairs in case of death or disability.
Providing for and protecting a spouse.
Providing for and protecting children.
Providing for and protecting grandchildren.
Disinheriting a family member.
Providing for charities at the time of death.
Plan for the transfer and survival of a family business.
Avoiding or reducing your estate taxes.
Avoiding probate.
Reduce administration costs at time of your death.
Avoiding a conservatorship (“living probate”) in case of a disability.
Avoiding will contests or other disputes upon death.
Protecting assets from lawsuits or creditors.
Preserving the privacy of affairs in case of disability or at time of death from business competitors, predators, dishonest persons and curiosity seekers.
Plan for a child with disabilities or special needs, such as medical or learning disabilities.
Protecting children’s inheritance from the possibility of failed marriages.
Protect children’s inheritance in the event of a surviving spouse’s remarriage.
Provide that your death shall not be unnecessarily prolonged by artificial means or measures.

Other Concerns (Please list below):

Important Family Questions

(Please check “Yes” or “No” for your answer)

	YES	NO
Are you (or your spouse) receiving Social Security, disability, or other governmental benefits? Describe ____________________________________________________
Are you (or your spouse) making payments pursuant to a divorce or property settlement order? Please furnish a copy
If married, have you and your spouse signed a pre- or post-marriage contract? Please furnish a copy
Have you (or your spouse) been widowed? If a federal estate tax return or a state death tax return was filed, please furnish a copy
Have you (or your spouse) ever filed federal or state gift tax returns?
Please furnish copies of these returns
Have you (or your spouse) completed previous will, trust, or estate planning? Please furnish copies of these documents
Do you support any charitable organizations now that you wish to make provisions for at the time of your death? If so, please explain below.
Are there any other charitable organizations you wish to make provisions for at the time of your death? If so, please explain below.
If married, have you lived in any of the following states while married to each other? Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington, or Wisconsin
Are you (or your spouse) currently the beneficiary of anyone else’s trust? If so, please explain below.
Do any of your children have special educational, medical, or physical needs?
Do any of your children receive governmental support or benefits?
Do you provide primary or other major financial support to adult children or others?

Additional Information

Owner of Property	Use
If own property in your name only	I
Joint Tenancy with someone other than a spouse, i.e. a child, parent, etc.	JTO
If you cannot determine how the property is owned	?

	General Description and/or Address	Owner	Market Value	Loan Balance	Total
1
2
3
4
5

	Type or Description	Owner	Market Value	Total
1
2
3
4
5

	Stocks, Bonds or Investment	Accounts	Type	Acct. Number	Owner	Amount	Total
1
2
3
4
5

	Name of Debtor	Date of Note	Maturity date	Owed to	Current Blanace	Total
1
2
3
4
5

Personal and Family Information Form

Your Concerns

Part II

Automobiles, Boats and RVs

Part III

	Client	Other’s	Total Value
Real Property
Furniture and Personal Effects
Automobiles, Boats and RV’s
Bank and Savings Accounts
Stocks and Bonds `
Life Insurance and Annuities
Retirement Plans
Business Interests
Money owed to you
Anticipated Inheritance, Etc.
Other Assets
Total Assets:

	Name	Birth date	Parent or Relationship	Comments
1
2
3
4
5

	Name	Relationship	Instructions or Guidelines
1
2
3
4
5

	Name	Relationship	Instructions or Guidelines
1
2
3
4
5

	Individual or Charity	Amount or Property
1
2
3
4