Personal Information Form - Streeter Law Group
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4Personal Information Form
*** All information contained in this form is confidential and protected by attorney-client privilege. ***
Completing this prior to your appointment will enable us to spend more time during the meeting
to answer your questions and help you identify solutions to your concerns.
□ US citizen □ Naturalized citizen □ resident alien
Client 1:
DOB:
□ retired □ employed
Veteran □ Yes
□ No
Occupation:
Marital status: □ single/widow(er) □ married (date
) □ first □ second □ other ______
Client 2 (if applicable):
.
DOB:
.DOD (if applicable)
.
□ US citizen □ Naturalized citizen □ resident alien
.□ retired □ employed
Occupation:
□ first marriage □ second marriage □ other
Veteran □ Yes
□ No
..
Address:
.
City:
.State:
.Zip Code
.
Home #
.Cell #
.Work #
.e-mail address
.
Which number(s) would you prefer to be contacted at? □ home □ cell □ work What is best time?
.
Referred to us by: Name:
Firm Name:
.
Contacts:
Financial Advisor
.Firm:
.Phone:
.
Accountant/tax:
.Firm:
.Phone:
.
Client 2 □ NA
Existing Estate Planning:
You
Date Document Executed
□ Yes □ No
□ Yes □ No
Will
Date:
.
□ Yes □ No
□ Yes □ No
Trust
Date:
.
□ Yes □ No
□ Yes □ No
Power of Attorney
Date:
.
□ Yes □ No
□ Yes □ No
Health Care Proxy
Date:
.
□ Yes □ No
□ Yes □ No
Living Will
Date:
.
□ Yes □ No
□ Yes □ No
Long-Term Care Insurance
Daily benefit:$
Term
.
Have you transferred or gifted away assets away in the last 60 months?
Amount $
.
Date:
.
Your health status plays an important role in the designing of an estate plan best suited for you and your loved ones.
You - current health status: □ Good □ Concern □ Problem
Client 2 - current health status: □ Good □ Concern □ Problem
Specific concern/problem:
Specific concern/problem:
You
Client 2
□ Yes How many?
□ No
□ Yes How many?
□ No
Do you have children:
□ joint □ you □ step □ adopted □ foster
□ joint □ you □ step □ adopted □ foster
Please specify:
□ Yes How many?
□ No
□ Yes How many?
□ No
Do you have grandchildren:
What would completing your estate planning accomplish for you?
?
What do you see as your biggest risk if you don’t complete your estate plan
Rank the following (1-8) in order of importance for you currently (1 = Most Important
8 = Least Important)
Avoid probate
Protect assets from govt/lawsuits/nursing homes
Keep estate matters private
Protect assets for family from predators after my death (i.e. my spouse’s disability
Minimize/eliminate taxes
or remarriage, my children’s/beneficiary’s lawsuits, divorce or bankruptcy)
Remain independent and in
Keep it simple for my family when something happens to me (disability/death)
control of my care and/or assets
Provide detailed instructions and authority to people I trust to have the care
I desire provided for me if I become disabled
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