Estate Planning Intake Form

124 Lake Street South
Long Prairie, MN 56347
Phone: 1-320-732-6112 Fax: 1-320-732-6023

ESTATE PLANNING AND WILL INFORMATION FORM
(Please print this form out and fill it out completely)

WHEN YOU HAVE COMPLETED THIS FORM, please return it to our office or bring it along to your scheduled office conference. We will rely upon this information you provide us to be accurate and complete in all respects. If the information is not accurate and complete, the recommendations we make may not be appropriate for your situation.

Name__________________________________Date of Birth_________Social Security No.________________

Spouse Name____________________________Date of Birth_________Social Security No.________________

Street Address______________________________Apt___County__________________________________

City____________________________State________________Zip Code__________________________

State of Residence___ Telephone #__________________W/Client________W/Spouse___________

a. Have you and your spouse signed a Premarital Agreement? Yes___No___ If you have, please bring a copy of it
to the interview.

b. Have you or your spouse been divorced? Yes___No___ If so, please bring a copy of the divorce decree
to the interview.

Please list ALL your children, including deceased children, children born out of wedlock, and children you
wish to omit from your estate plan.

Name of Child	Date of Birth	Address	Child of
.	.	.	.
.	.	.	.
.	.	.	.
.	.	.	.
.	.	.	.
.	.	.	.

Identify any child who is not a natural or adopted child of both you and your spouse.

____________________________________________________________________________________

a. Have any children received an advance on their inheritance or are any children financially indebted to you?

If so, Please explain__________________________________________________________________

_________________________________________________________________________________

b. Is there any reason NOT to treat your children equally? If so, please explain_______________________

_________________________________________________________________________________

c. Are any of the children under a disability?___________________________________________________

__________________________________________________________________________________

d. Do you have any special concerns or objectives regarding your children? ___________________________

____________________________________________________________________________________

e. Guardians. Who should be guardian of your minor children? (a guardian has physical and legal control over
your children until they reach the age of 18)

Name:______________________________________________________________________________

Address:____________________________________________________________________________

Alternate Guardian:_____________________________________________________________________

4. Personal Representative. Who should be Personal Representative ("executor") of your estate? A personal
Representative is responsible for probating your will, paying your debts, collecting your assets and settling your
estate.

Name:________________________________Relationship to you:_______________________________

Address:____________________________________________________________________________

Alternate Personal Representative:_________________________Relationship to you:_________________

Address:____________________________________________________________________________

5. Trusts
    If a trust is appropriate to include in your estate plan, who should be the trustee? A trustee is the person or entity
    who is responsible for managing the assets placed into the trust. A trustee manages the assets for your children
    or other beneficiaries until they reach specified ages. If you do not establish a trust, children inherit at age 18.
    You may name an individual, bank or trust company, or both to act as your trustee.

Name:_________________________________________________________________________________

Address:_______________________________________________________________________________

Alternate Trustee:________________________________________________________________________

Address:_______________________________________________________________________________

6. Financial Inventory
    Use approximate values under each person showing ownership of each asset. PLEASE BRING SUPPORTING
    DATA FOR EACH ASSET, i.e. bank statements, retirement reports, stock and bond account reports, etc.
    NOTE: If you are entering into a revocable (living) trust, please bring copies of deeds to the real estate you own.

Assets	Name of Bank Holding Account	Husband	Wife	Joint
Checking Account	.	$	$	$
Savings Account	.	$	$	$
Money Market Acct.	.	$	$	$
Stocks & Bonds	.	$	$	$
Closely Held Business Interest	.	$	$	$
Life Insurance (Face)	.	$	$	$
On Husband's life	.	$	$	$
On Wife's life	.	$	$	$
Retirement Accounts	.	$	$	$
IRA	.	$	$	$
Pension	.	$	$	$
Profit Sharing/401K	.	$	$	$
Home	.	$	$	$
Other Real Estate	.	$	$	$
Automobile	.	$	$	$
Personal Property	.	$	$	$
Other Assets	.	$	$	$
.	,	$	$	$
Total	.	$	$	$

Liabilities	Name of Company	Husband	Wife	Joint
Home Mortgage	.	$	$	$
Other Mortgages	.	$	$	$
Debts to Family Members	.	$	$	$
Other Debts (describe)	.	$	$	$
.	.	.	.	.
.	.	.	.	.
.	.	.	.	.
Total Liabilities	.	$	$	$

Policy Name/Number	Face Value	Owner	Insured	Beneficiary
1.	$	.	.	.
2.	$	.	.	.
3.	$	.	.	.
4.	$	.	.	.
5.	$	.	.	.

b. Retirement Plans. Please list your retirement plans/IRA's; value of each and the beneficiary of each.

c. Does your retirement plan have a death benefit? Yes__No__ If so, who is the named beneficiary?

_____________________________________________________________________________________

8. Personal Property
Describe and give a value of any items of substantial value, such as automobiles, works of art, jewelry, etc. Be
sure to include any items listed on an insurance rider.

Description	Approximate Value
Personal Property	.
Automobiles	.
Collectibles	.
Jewelry	.
Boats/Airplanes	.
Other	.
.	.
.	.
.	.
.	.
.	.

Do you have a safe deposit box? Yes___No___ If so, where?_____________________________________

Does anyone else have access to your box? ___________________________________________________

10. Future Inheritances
Do you expect any inheritance in the near future? If so please give details____________________________

___________________________________________________________________________________

____________________________________________________________________________________

Accountant__________________________________________________________________________

Address_________________________________________________Telephone____________________

Financial Advisor______________________________________________________________________

Address_________________________________________________Telephone____________________

12. Special Requests
Special requests regarding funeral, cremation, or burial instructions are best handled by a Letter of Instruction or other statement (see separate from your will) to your family or other responsible person. Organ donation is best handled in a Health Care Directive and noted on the person's drivers license.

Go here for information that would be helpful if you wish to prepare a Health Care Directive

Company/Bank	Value	Beneficiary
.	$	.
.	$	.
.	$	.
.	$	.
.	$	.
.	$	.