Intake Checklist - Pugh Moak P.C.

General Information

Appointment Date

CLIENT 1*

Full Legal Name (First, Middle and Last)

Date of Birth (1)

CLIENT 2

Full Legal Name (First Middle and Last)

Date of Birth (2)

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone*

(Client 1)

Primary Phone

(Client 2)

E-MAIL ADDRESS*

(Client 1)

E-MAIL ADDRESS

(Client 2)

U.S. CITIZEN?

(Client 1)

Yes

U.S. CITIZEN?

(Client 2)

Yes

ARE CLIENTS MARRIED TO EACH OTHER

Yes

CHILDREN: (First, Middle and Last Names)

Name

Date of Birth (mm/dd/yyyy)

Address & Phone Number

GRANDCHILDREN: (First, Middle and Last Names)

Name

Date of Birth (mm/dd/yyyy)

Names of Parents

Address & Phone Number

*If any grandchildren do not reside with your child, please list the grandchild’s address as well.

Do you have any deceased Children?

Yes

Living Children of deceased Children

DO YOU PRESENTLY HAVE A TRUST?

Yes

Please upload a copy of your trust, if any.

Accepted file types: jpg, doc, png, pdf, ppt, docx, Max. file size: 32 MB.

DO YOU PRESENTLY HAVE A WILL?

Yes

If Yes, Location of Safe Deposit Box

Date of execution and where you lived at the time of execution.

YOUR ASSETS

LIFE INSURANCE:

NAME OF INSURED

AMOUNT

BENEFICIARY

COMPANY

Name and Phone Number of Life Ins. Agent, if any:

VALUE OF HOUSE:

PLEASE ATTACH LEGAL DESCRIPTION FROM A DEED, TITLE POLICY OR MORTGAGE AND NOT FROM A TAX BILL.

Accepted file types: jpg, doc, png, pdf, ppt, docx, Max. file size: 32 MB.

IN WHOSE NAME(S) IS THE HOUSE TITLED?

VALUE OF CONTENTS:

VALUE OF ANY COLLECTIONS NOT LISTED IN CONTENTS:

DO YOU HAVE A SAFE DEPOSIT BOX?

Yes

LOCATION

VALUE OF STOCKS, BONDS, MUTUAL FUNDS, ANNUITIES AND OTHER INVESTMENT ACCOUNTS: $

Name and Phone Number of Broker, If Any:

OTHER REAL ESTATE:

Address

Value

Names of all owners

IF ANY(OTHER REAL ESTATE), ATTACH LEGAL DESCRIPTION FROM A DEED

Accepted file types: jpg, doc, png, pdf, ppt, docx, Max. file size: 32 MB.

BANK ACCOUNTS, SAVINGS AND LOAN OR CREDIT UNIONS:

FINANCIAL INSTITUTION

TYPE

AMOUNT

OWNER

Any gift tax return filed

Yes

Years filed

Vehicles

VALUE

OWNER

VALUE OF BUSINESS:

HOW OWNED?

ANY BUSINESS BUY-SELL AGREEMENTS?:

Please Attach a Copy of the Buy-sell Agreement, If Any.

Accepted file types: jpg, doc, png, pdf, ppt, docx, Max. file size: 32 MB.

If there are any IRA, pension plan or profit sharing agreements in existence for your benefit, please list the present value of the plan, whether or not you are vested and whether there is any death benefit or continuing benefit for your spouse.

PLAN

OWNER

VALUE

VESTED?

BENEFICIARY

Other Assets Not Previously Listed, Such as Boats, Motor Homes or Amounts Owed to You by Others, Etc.:

ASSET

VALUE

OWNER(S)

Value of Any Memberships Which Could Be Sold at Your Death:

DEBTS

HOUSE:

OTHER REAL ESTATE:

Vehicles

OTHER LIABILITIES INCLUDING ANY LOANS YOU MAY HAVE CO-SIGNED ON FOR OTHERS:

AMOUNT

LIEN HOLDER

SECURED ASSETS

Does the lien holder offer insurance on the outstanding balance?

LIST SIGNIFICANT DEBTS OR OBLIGATIONS OTHER THAN MORTGAGES LISTED ABOVE.

At the time of the interview you should be in a position to discuss previous marriages, if any, specific situations involving children or other beneficiaries which could affect your estate plan, any expected inheritances, and all primary beneficiaries and contingent beneficiaries, including relatives friends and charities.

If you have ever lived in a state which has a community property law, such as California, Texas, New Mexico, Arizona, Washington, Louisiana, Nevada, or Idaho, please be prepared to discuss assets brought from those states into this state.

You should be in a position to list specific assets, if any, which definitely should go to one beneficiary as opposed to any others.

Before meeting with us, please consider who will be guardian for any of your unmarried minor children and who should be personal representative of your estate and trustee of your trust. The personal representative and/or trustee could be a bank or other financial institution, your spouse, your children, a friend or a financial advisor.

Representatives

Administrator

Name

Address

Phone Number

Alternate Administrator

Name

Address

Phone Number

Guardian:

Name

Address

Phone Number

Alternate Guardian:

Name

Address

Phone Number

Power of Attorney - Financial Agent (client 1)

Name

Address

Phone Number

Alternate Power of Attorney - Financial Agent (client 1)

Name

Address

Phone Number

Power of Attorney - Financial Agent (client 2)

Name

Address

Phone Number

Alternate Power of Attorney - Financial Agent (client 2)

Name

Address

Phone Number

Power of Attorney - Medical Agent (client 1)

Name

Address

Phone Number

Alternate Power of Attorney - Medical Agent (client 1)

Name

Address

Phone Number

Power of Attorney - Medical Agent (client 2)

Name

Address

Phone Number

Alternate Power of Attorney - Medical Agent (client 2)

Name

Address

Phone Number

Please use the space below to outline any specific wishes you may have with regard to the proposed disposition of your estate. If there are any charities to which you would like to leave a gift, please specify the charity(ies) by proper name and the amount of the gift either as a dollar value or percentage of your estate in the space below.

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