"ESTATE PLANNING / GUARDIANSHIP INTERVIEW FORM"

Please fill out completely and fax or mail back. This form is extremely important. Your accuracy and completeness in responding will help me best represent you.
ALL THE PAGES AND SECTIONS OF THIS FORM MUST BE COMPLETED PRIOR TO SEEING THE ATTORNEY. WRITE YOUR SPECIFIC QUESTIONS AT THE END OF THE LAST PAGE. PLEASE HELP YOURSELF TO THE FREE INFORMATION BROCHURES IN THE RECEPTION AREA.
PLEASE PRINT CLEARLYPerson for whom planning desired:
______________________________________________________First Last
Street Address: ________________________________________
City ____________________ State ____ Zip Code _____________
Telephone Numbers: Cell: __________________________________
Day: ____________________ /Night: ________________________
E-mail address: __________________________________________
Referred By: ___________________________________________
Today's Date ___________________________________________
1. Name of person filling out this interview sheet, if different than above:
____________________________________________________________
2. Current address and phone for person whom Estate Planning is sought:
____________________________________________________________
____________________________________________________________
3. Relationship of person filling out this interview sheet, if not person needing planning:
____________________________________________________________
4. Special medical or financial needs of person, spouse and dependents:
____________________________________________________________
____________________________________________________________
____________________________________________________________
ASSETS
5. Stocks, bonds and other securities. How Registered. Approximate Amount of Each. (Joint - Survivorship - P.O.D. - Trust - Custodial) If none, write none:
____________________________________________________________
____________________________________________________________
____________________________________________________________
6. Real Estate: Location and General Description - Record Owners -How and When Acquired, Estimated Value - Mortgages, Approximate Amount of Each: If none, write none:
____________________________________________________________
____________________________________________________________
____________________________________________________________
7. Bank and Savings & Loan Association Accounts: Savings - Time Cert. - Checking - other. How registered (Joint, Survivorship, Trust, Custodial)If none, write none:BANK APPROXIMATE AMOUNT BENEFICIARY
____________________________________________________________
____________________________________________________________
____________________________________________________________
8. Major Personal Effects: Including Furs, Jewelry, Art, Cash on Hand and other items of Substantial Value and the Approximate Amount of Each:If none, write none:
____________________________________________________________
____________________________________________________________
____________________________________________________________
9. Other Investments: Nature and in What Names(s) Held and the Approximate Amount of Each:If none, write none:
____________________________________________________________
____________________________________________________________
____________________________________________________________
10. Insurance policies, pensions, retirement and death benefits:(Identification and beneficiary) If none, write none:
COMPANY AMOUNT OF POLICY BENEFICIARY
____________________________________________________________
____________________________________________________________
____________________________________________________________
11. Safe Deposit Box: Location and How Registered: If none, write none:
____________________________________________________________
12. Liabilities More Than $2,000.00: If none, write none:
____________________________________________________________
____________________________________________________________
____________________________________________________________
13. Estimated Gross Estate:
$_________________________________________________________
14. A. Is there a Will? _____ Did you bring a photocopy? ____
B. Is there a Power of Attorney? _____ Did you bring a copy? ____
C. Do You Have a Copy of the Deed? ________
D. Did You have/ bring a List of Assets? _________
15. PLEASE USE THIS PAGE TO WRITE YOUR SPECIFIC QUESTIONS FOR THE ATTORNEY:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
ESTATE PLANNINGThe estate may be subject to Federal Estate Taxation if the total of assets exceeds $200,000. If the assets exceed $2,000,000 and you desire estate planning to avoid or reduce your estate tax or require a Trust to protect a spouse, please advise Mr. Vercammen. A Standard Will is not designed to address estate tax issues. We do not do Tax Planning or Medicaid Planning.