Personal And Financial Information Form
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4Personal and Financial Information Sheet
*** All information contained in this form is confidential and protected by attorney-client privilege. ***
Name: ________________________________ DOB: _________________ □ US citizen □ Naturalized citizen □ resident alien
occupation: ___________________________________________________________________________□ retired □ employed
Marital status: □ single/widow(er) □ married (date _________) □ first □ second □ other ______ Social Security No.: _____________
Spouse (if applicable): _________________________________ DOB: ______________ DOD (if applicable) _________________
□ US citizen □ Naturalized citizen □ resident alien
occupation: _________________________________□ retired □ employed
□ first marriage □ second marriage □ other ______ Social Security 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: ________________________________
Financial Advisor :_________________________ Firm: __________________ Phone: _______________________
Contacts:
Accountant: ______________________________ Firm: __________________ Phone: _______________________
Spouse □ NA
Existing Estate Planning:
You
Date Document Executed
Will
□ Yes □ No
□ Yes □ No
Date: _____________________
Trust
□ Yes □ No
□ Yes □ No
Date: _____________________
Power of Attorney
□ Yes □ No
□ Yes □ No
Date: _____________________
Health Care Proxy
□ Yes □ No
□ Yes □ No
Date: _____________________
Living Will
□ Yes □ No
□ Yes □ No
Date: _____________________
Long-Term Care Insurance
□ Yes □ No
□ Yes □ No
Daily benefit: _____________________
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
Specific concern/problem:
Spouse - current health status: □ Good
□ Concern
□ Problem
Specific concern/problem:
Spouse NA
You
Do you have children:
□ Yes How many? ______
□ No
□ Yes How many? ______
□ No
Please specify:
□ joint □ you □ step □ adopted □ foster
□ joint □ you □ step □ adopted □ foster
Do you have grandchildren:
□ Yes How many? ______
□ No
□ Yes How many? ______
□ No
Please specify:
□ joint □ you □ step □ adopted □ foster
□ joint □ you □ step □ adopted □ foster
Is there anyone in your family with special needs or that requires special consideration?
□ Yes
□ No
Comments/ Concerns:
What do you want us to help you accomplish? _____________________________________________________________________
Is there anything else about you or your family or your personal goals you would like to tell us?
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Parent category: Business