Personal Information Form - David L. Carrier
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4Personal Information Form
All information contained in this form is confidential and protected by
attorney-client privilege
Basic Information
□
□
Name:
DOB:
Male
Female
Address:
Social Sec. No.
City, State, Zip:
Home #:
Email:
Work #:
Veteran? □ Y □ N
Occupation:
Cell #:
Check all that apply: □ married □ divorced □ not married □ widow(er) □ living with partner □ first marriage □ 2nd □ 3rd □ ____th
Spouse
(if applicable)
□
□
Name:
DOB:
DOD:
(if applicable)
Male
Female
Email:
Social Sec. No.
Veteran? □ Y □ N
Occupation:
Phone #:
Check all that apply: □ married □ divorced □ not married □ widow(er) □ living with partner □ first marriage □ 2nd □ 3rd □ ____th
Professional Contacts
(if applicable)
Financial Advisor _________________________ Firm _____________________ Phone ___________________
Accountant ______________________________ Firm _____________________ Phone ___________________
Estate Planning
Do you have any existing estate planning documents?
You
Spouse
When was document executed?
□ Yes □ No
□ Yes □ No
Will:
_________________________
□ Yes □ No
□ Yes □ No
Trust:
_________________________
□ Yes □ No
□ Yes □ No
Power of Attorney:
_________________________
□ Yes □ No
□ Yes □ No
Health Care Proxy:
_________________________
□ Yes □ No
□ Yes □ No
Living Will:
_________________________
□ Yes □ No
□ Yes □ No
Long-Term Care Insurance:
_________________________
Health Status
Understanding your current health status plays an important role in designing an estate plan best suited
for the needs of you and your loved ones.
Your current health status: □ Good □ Concern □ Problem
Spouse: □ Good □ Concern □ Problem
Please specify: ______________________________________________________________________________
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