This form is to help us understand what you have in place so far and what the financial picture looks like. This information will help us figure out the best plan of action for your protection. Please fill out as much of the information as possible to the best of your ability.
Feel free to save and exit and come back later to work on it. There is a lot of information requested and is best to work on it for a while and come back later.
Section 1: Contact Person
Are you the person seeking services for yourself?
Yes
No
Prefix
First Name
Middle Name
Last Name
Email Address
Phone Number
Physical Address
Mailing Address
City
State/Province
Zip/Postal Code
Do you have a power of attorney from the person(s) seeking services? (Please answer Yes or No)
Do you have guardianship over the person(s) seeking services? (Please answer Yes or No)
Do you have conservatorship over the person(s) seeking services? (Please answer Yes or No)
Are you a child of the person(s) seeking services? (Please answer Yes or No)
Other type of relationship?
Section 2: Personal data of person(s) seeking services
Contact information: First Person's Information
Prefix
First name
*
Middle name
Last name
*
Date of birth
Emails
Address
*
Type
Upon submission, a copy of this form will be sent to the primary email.
Work
Home
Other
Primary
Default email false
Add email
Addresses
Street address
Country
Australia
Canada
United Kingdom
United States
---------------
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czechia
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Türkiye
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
City
State/Region
Alaska
Alabama
Arkansas
American Samoa
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Guam
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Northern Mariana Islands
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
United States Minor Outlying Islands
Utah
Virginia
Virgin Islands, U.S.
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Province/Region
Zip/Postal code
Address type
Work
Billing
Home
Other
Primary
Default address false
Add address
Phone numbers
Phone number
Type
Work
Home
Mobile
Fax
Pager
Skype
Other
Primary
Add phone number
What is the first person's county of residence?
Is the first person's mailing address different than the street address above?
Yes
Mailing Address
City
State
Zip
No
What are the last 4 digits of the first person's Social Security Number?
What is the first person's gender?
Male
Female
How does the first person sign his/her name?
Spouse's Information
Contact information: Spouse's Information
(If Applicable)
Is the first person married?
Yes
Spouse's Prefix
Spouse's First Name
Spouse's Middle Name
Spouse's Last Name
Spouse's Date of Birth
Spouse's Social Security Number (Last 4 digits only)
Spouse's Email
Spouse's Phone Number
If the home address is different than First Person, please enter it here
How does the Spouse sign his/her name?
No
Section 3: Children's Information
Do you have a child? If so, child's information:
Yes
First Name:
Middle Name:
Last Name:
Social Security Number:
Email:
Phone Number:
Address:
City:
State:
Zip:
Is the child an adult?
If the child is married, please provide spouses name?
Is the child disabled?
Is the child from the Marriage? If not, please designate which person seeking services is the child's parent.
Is the child deceased?
No
Do you have a second child? If so, second child's information:
Yes
First Name:
Middle Name:
Last Name:
Social Security Number:
Email:
Phone Number:
Address:
City:
State:
Zip:
Is the child an adult?
If the child is married, please provide spouses name?
Is the child disabled?
Is the child from the Marriage? If not, please designate which person seeking services is the child's parent.
Is the child deceased?
No
Do you have a third child? If so, third child's information:
Yes
First Name:
Middle Name:
Last Name:
Social Security Number:
Email:
Phone Number:
Address:
City:
State:
Zip:
Is the child an adult?
If the child is married, please provide spouses name?
Is the child disabled?
Is the child from the Marriage? If not, please designate which person seeking services is the child's parent.
Is the child deceased?
No
Do you have a fourth child? If so, fourth child's information:
Yes
First Name:
Middle Name:
Last Name:
Social Security Number:
Email:
Phone Number:
Address:
City:
State:
Zip:
Is the child an adult?
If the child is married, please provide spouses name?
Is the child disabled?
Is the child from the Marriage? If not, please designate which person seeking services is the child's parent.
Is the child deceased?
No
Do you have a fifth child? If so, fifth child's information:
Yes
First Name:
Middle Name:
Last Name:
Social Security Number:
Email:
Phone Number:
Address:
City:
State:
Zip:
Is the child an adult?
If the child is married, please provide spouses name?
Is the child disabled?
Is the child from the Marriage? If not, please designate which person seeking services is the child's parent.
Is the child deceased?
No
Section 4: Real Estate and Minerals
In this section, we are only asking about real estate and minerals you may own. If additional financial information is needed, we will request it at a later time.
Do you own your own home?
Yes
What is the estimated value of the home?
What is the street address or legal description of the home?
If the home is located outside the city limits, how many acres is it on?
Does this location produce income? (i.e., No, Renting, Farming, etc...)
No
Do you own a second property?
Yes
What is the estimated value of the property?
What is the street address or legal description of the property?
How many acres comprises this property?
Does this property produce income? (i.e., No, Renting, Farming, etc...)
No
Do you own a third property?
Yes
What is the estimated value of the property?
What is the street address or legal description of the property?
How many acres comprises this property?
Does this property produce income? (i.e., No, Renting, Farming, etc...)
No
Do you own a fourth property?
Yes
What is the estimated value of the property?
What is the street address or legal description of the property?
How many acres comprises this property?
Does this property produce income? (i.e., No, Renting, Farming, etc...)
No
Do you own a fifth property?
Yes
What is the estimated value of the property?
What is the street address or legal description of the property?
How many acres comprises this property?
Does this property produce income? (i.e., No, Renting, Farming, etc...)
No
Do you own minerals not described in the above questions?
Yes
What is the legal description or street address of these minerals?
If the minerals are producing, how much income do you receive from those minerals per year?
Who leases the minerals?
If the minerals are not producing, how many mineral acres do you own?
No
Do you own additional minerals not described in the above questions?
Yes
What is the legal description or street address of these minerals?
If the minerals are producing, how much income do you receive from those minerals per year?
Who leases the minerals?
If the minerals are not producing, how many minerals acres do you own?
No
Do you own additional minerals not described in the above questions?
Yes
What is the legal description or street address of these minerals?
If the minerals are producing, how much income do you receive from those minerals per year?
Who leases the minerals?
If the minerals are not producing, how many mineral acres do you own?
No
Do you own additional minerals not described in the above questions?
Yes
What is the legal description or street address of these minerals?
If the minerals are producing, how much income do you receive from those minerals per year?
Who leases the minerals?
If the minerals are not producing, how many mineral acres do you own?
No
Do you own additional minerals not described in the above questions?
Yes
What is the legal description or street address of these minerals?
If the minerals are producing, how much income do you receive from those minerals per year?
Who leases the minerals?
If the minerals are not producing, how many mineral acres do you own?
No
Section 5: Planning Information
Upon death of the Client (and Spouse), how are the assets to be distributed?
Personal Representative of Will and Trustee of Trust. If more than one person is to serve, are they to serve consecutively or concurrently? If consecutively, please list in the order they are to serve.
Consecutively (Serving individually one after another)
Name of 1st Trustee:
Name of 2nd Trustee:
Name of 3rd Trustee:
Name of 4th Trustee:
Name of 5th Trustee:
Concurrently (Serving together)
Name of 1st Trustee:
Name of 2nd Trustee:
Name of 3rd Trustee:
Name of 4th Trustee:
Name of 5th Trustee:
If Trustees are serving, how are they to serve? (Anyone can act alone, Majority Vote, Unanimous Consent)
Appointment of Agent under Power of Attorney. If more than one person is to serve, are they to serve consecutively or concurrently? If consecutively, please list in the order they are to serve.
Consecutively (Serving Individually one after another)
1st AGENT NAME:
1st Agent Relationship:
1st Agent Address:
1st Agent Phone Number:
2nd AGENT NAME:
2nd Agent Relationship:
2nd Agent Address:
2nd Agent Phone Number:
3rd AGENT NAME:
3rd Agent Relationship:
3rd Agent Address:
3rd Agent Phone Number:
4th AGENT NAME:
4th Agent Relationship:
4th Agent Address:
4th Agent Phone Number:
5th AGENT NAME:
5th Agent Relationship:
5th Agent Address:
5th Agent Phone Number:
Concurrently (Serving Together)
1st AGENT NAME:
1st Agent Relationship:
1st Agent Address:
1st Agent Phone Number:
2nd AGENT NAME:
2nd Agent Relationship:
2nd Agent Address:
2nd Agent Phone Number:
3rd AGENT NAME:
3rd Agent Relationship:
3rd Agent Address:
3rd Agent Phone Number:
4th Agent NAME:
4th Agent Relationship:
4th Agent Address:
4th Agent Phone Number:
5th AGENT NAME:
5th Agent Relationship:
5th Agent Address:
5th Agent Phone Number:
If agents are serving, how are they to serve? (Anyone can act alone, Majority Vote, Unanimous Consent)
Appointment of Health Care Proxy under Advance Directive for Health Care. If more than one person is to serve, are they to serve consecutively or concurrently? If consecutively, please list in the order they are to serve.
Consecutively (Serving individually one after another)
1st TO SERVE NAME:
1st to serve Relationship:
1st to serve Address:
1st to serve Phone Number:
2nd TO SERVE NAME:
2nd to serve Relationship:
2nd to serve Address:
2nd to serve Phone Number:
3rd TO SERVE NAME:
3rd to serve Relationship:
3rd to serve Address:
3rd to serve Phone Number:
4th TO SERVE NAME:
4th to serve Relationship:
4th to serve Address:
4th to serve Phone Number:
5th TO SERVE NAME:
5th to serve Relationship:
5th to serve Address:
5th to serve Phone Number:
Concurrently (Serving together)
1st TO SERVE NAME:
1st to serve Relationship:
1st to serve Address:
1st to serve Phone Number:
2nd TO SERVE NAME:
2nd to serve Relationship:
2nd to serve Address:
2nd to serve Phone Number:
3rd TO SERVE NAME:
3rd to serve Relationship:
3rd to serve Address:
3rd to serve Phone Number:
4th TO SERVE NAME:
4th to serve Relationship:
4th to serve Address:
4th to serve Phone Number:
5th TO SERVE NAME:
5th to serve Relationship:
5th to serve Address:
5th to serve Phone Number:
If healthcare proxiel are serving, how are they to serve? (Anyone can act alone, Majority Vote, Unanimous Consent)
Section 6: Referral Information (Optional)
Please let us know how you heard of us!
How did you hear about our Services?
Seminar
Friend
Financial Advisor
Nursing Home
Accountant
Attorney
Website
Article Publication
Name of Referral:
Entry Date