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Hellmuth & Johnson PLLC

8050 West 78th Street, Minneapolis, MN 55439
LOCAL 952-941-4005
FREE 888-343-3918
FAX 952-941-2337
info@hjlawfirm.com

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CONFIDENTIAL ESTATE PLANNING INTAKE FORM

This form is helpful as we assist you in meeting your estate planning objectives. Please fill out as much as possible using estimated figures where information is not easily attainable, and leaving blanks for those questions which are inapplicable. Please feel free to e-mail us if you have other information that you think might be helpful.

A. Background Information

    Client A Client B
1. Full legal name:
2. Principal Residence:
   
  Telephone:
  Cell phone:
  E-Mail:
3. Profession/Business:
4. Dates of Birth:
5. Citizenship-USA?

B. Family Information

Children

1. Name: Date of Birth:
  Address:
  Married? Yes No If so, name of spouse:
2. Name: Date of Birth:
  Address:
  Married? Yes No If so, name of spouse:
3. Name: Date of Birth:
  Address:
  Married? Yes No If so, name of spouse:
4. Name: Date of Birth:
  Address:
  Married? Yes No If so, name of spouse:

Grandchildren (if any) or Other Beneficiaries

1. Name: Date of Birth:
2. Name: Date of Birth:
3. Name: Date of Birth:
4. Name: Date of Birth:
5. Name: Date of Birth:

C. Financial Information

Approximate Annual Income

    Client A Client B
1. Salary/commissions:
2. Investment income:
3. Bonuses:
4. Other income:

Approximate Asset Value

  Client A Client B Joint
Home (est. FMV):
Other real estate:
Cash or near cash:
Investment accounts:
Stocks:
Bonds:
Personal possessions:
Life Insurance:
Retirement accounts:
Pension Plans:
Annuities:
Monies owed to you:
Partnership/LLCs:
Corporate Business:
Sole Proprietorship:

Significant Liabilities (Mortgages, other debts, adverse legal judgments, etc.)

  Client A Client B
Real estate mortgages:
Loans against life insurance:
Loans payable:
Accounts payable:
Unpaid taxes:
Other obligations:

D. Special Considerations

1. Do you have any existing estate planning documents (wills, trusts, health care directives, etc.)?
  Explain:
2. Do you expect to inherit significant wealth from parents or other relatives?
  Explain:
3. Does anyone in your family need special medical care?
  Explain:
4. Have you been previously married? Yes No
5. Do you have a pre-marital or post-marital agreement? Yes No
6. To your knowledge, are you a beneficiary under any existing trusts?
  Explain:
7. Please give thought to individuals (or corporate trustees) who may be appropriate to serve in the following roles:
  Client A Client B
  Personal Representative: Name
  Address
 
  Successor Personal Rep: Name
  Address
 
 
  Trustee of Trust(s): Name
  Address
 
 
  Successor Trustee: Name
  Address
 
 
  Guardian(s) of Minor Child: Name
  Address
 
 
  Successor Guardian(s): Name
  Address
 
 
  Power of Attorney(s): Primary
  Address
 
    Secondary
  Address
 
 
  Health Care Agent(s): Primary
  Address
 
  Phone
 
  Health Care Agent(s) cont.: Secondary
  Address
 
  Phone
 
7. Have you made any significant gifts of money or property during life?
Yes No
  If yes, Explain:

E. Estate Planning Objectives

Please describe any significant estate planning objectives or concerns.

F. Do you prefer to meet with a particular attorney? If so, please specify:

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