Personal & Financial Information Form

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PERSONAL INFORMATION FORM

YOUR PERSONAL INFORMATION

Full Legal Name*

Date of Birth*

Primary Phone*

Email*

Address (Street, City, Zip)*

Employment Status*

Occupation

Are you a Veteran?*

If you are a Veteran, please indicate dates served:

Citizenship

Marital Status*

Date of Current Marriage

***If you are not married, skip this section***

SPOUSE PERSONAL INFORMATION

Spouse Full Legal Name

Spouse Date of Birth

Spouse Primary Phone (if different from yours)

Spouse Email

Spouse Address (Street, City, Zip) (if different from yours)

Spouse Employment Status

Spouse Occupation

Is Spouse a Veteran?

If Spouse is a Veteran, please indicate dates served:

Spouse Citizenship

Spouse Date of Death (if applicable)

EXISTING ESTATE PLANS

Please indicate all previous estate planning documents you have executed:

Last Will and Testament

Date Executed

Trust

Date Executed

Financial Power of Attorney

Date Executed

Healthcare Power of Attorney

Date Executed

Please indicate all previous estate planning documents your spouse (if applicable) has executed:

Last Will and Testament

Date Executed

Trust

Date Executed

Financial Power of Attorney

Date Executed

Healthcare Power of Attorney

Date Executed

What would completing your estate plan accomplish for you?

What do you see as your biggest risk if you don't complete your estate plan?

HEALTH STATUS

Your health status plays an important role in the designing of an estate plan best suited for you and your loved ones.

Please indicate your overall current health status:

Specific Health Concern or Problem

Please indicate your spouse's overall current health status:

Specific Health Concern or Problem

CHILDREN

Child 1 Name

Parentage

Child 2 Name

Parentage

Child 3 Name

Parentage

Child 4 Name

Parentage

Child 5 Name

Parentage

Child 6 Name

Parentage

LONG-TERM CARE PLANNING CONSIDERATIONS

Your future potential long-term care needs can play an important role in developing an estate plan best suited for your lifelong goals.

Please indicate the following assets you own:

Long-Term Care Insurance

Daily Benefit: $

Length of Benefit:

Burial Plot

Location:

Pre-Need Funeral Contract

Value: $

Location:

Indicate the following assets your spouse owns (if applicable):

Long-Term Care Insurance

Daily Benefit: $

Length of Benefit:

Burial Plot

Location:

Pre-Need Funeral Contract

Value: $

Location:

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