Estate Planning Intake

Basic Information

Today's Date(Required)

Your Full Name

Your Email(Required)

What is your street address?

What city do you reside in?

What county do you reside in?

What state do you reside in?

What is your zip code?

Family

Are you married?(Required)

Yes

No

Your Spouse’s Name

Do you have child(ren)?(Required)

Yes

No

Number of child(ren)

Please provide the full name for each of your children:

Add one row per child.

Gifts and Beneficiaries

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Do you want to leave a specific item, amount of money, or piece of property to someone? If yes, describe it:

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Name the person who should receive this gift:

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If the above named person passes away before you, who should get this gift instead?

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Who should receive the rest of your estate (everything else you own)? (Enter full name(s))

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If that person has already passed away, who should receive instead?

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If the two groups of people or persons named above have already passed away, who should receive instead?

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If the above named person(s) passes away, who should receive instead?

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If the above named person(s) passes away, who should receive instead?

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Name anyone that you want to specifically leave out of your will:

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Do you want to list “backup” recipients?(Required)

Yes

No

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If anything is left over, who should receive it? (This is your “backup” person/people):

In your own words, please describe what you want your estate plan to accomplish. (Required)

Include who you want to receive your assets, who should receive them if your primary beneficiaries do not survive you, and any goals or concerns you have (such as minimizing probate, protecting beneficiaries, tax planning, charitable giving, or providing for loved ones with special needs). Your attorney will use this information to draft documents that legally reflect your intent.

Fiduciary Appointments

Name of the person you trust to manage money/property for a minor or disabled beneficiary:

If that person cannot serve, who should serve instead?

If that person also cannot serve, who should serve instead?

Do you want to appoint a guardian for your minor child(ren) in the event of your death or incapacity?

Yes

No

If you have minor children, who should be their legal guardian if you pass away?

If that person cannot serve, who should serve instead?

Who do you want to be your Executor (the person who carries out your Will)?

Do you want the Executor to be compensated for their services?

Yes

No

If that person cannot serve, who should serve instead?

If that person also cannot serve, who should serve instead?

Who is your primary attorney?(Required)

Chavon Carr

Gere Cole

Medical Power of Attorney

Full name of the person you want to make your health care decisions if you cannot

Relation with the person you want to make your health care decisions if you cannot

Address of the person you want to make your health care decisions if you cannot

Phone Number of the person you want to make your health care decisions if you cannot

When should this Medical Power of Attorney take effect?

This medical power of attorney takes effect if I become unable to make my own health care decisions and this fact is certified in writing by my physician.

This medical power of attorney is effective upon execution and is not affected by my subsequent disability or incapacity.

If your primary health care agent is unavailable, who should serve (as Alternate Health Care Agent) instead? (Full name)

Relation with the Alternate Health Care Agent, If your primary health care agent is unavailable

Address of Alternate Health Care Agent, If your primary health care agent is unavailable

Phone Number of Alternate Health Care Agent, If your primary health care agent is unavailable

If your alternate health care agent also unavailable, who should serve (as Second Alternate Health Care Agent) instead? (Full name)

Relation with the Second Alternate Health Care Agent, If your alternate health care agent is unavailable

Address of Second Alternate Health Care Agent, If your alternate health care agent is unavailable

Phone Number of Second Alternate Health Care Agent, If your alternate health care agent is unavailable

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HIPAA Authorization / Medical Release

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Full name of the person you want to give access to your medical information

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Address of the person you want to give access to your medical information (street, city, state, zip)

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Phone number of the person you want to give access to your medical information

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If your primary agent is unavailable, who should have access instead? (Full name)

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Address of Alternate Medical Release Agent, If your primary agent is unavailable

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Phone Number Alternate Medical Release Agent, If your primary agent is unavailable

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Witnesses

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Name of Witness 1

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Address of Witness 1

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Name of Witness 2

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Address of Witness 2

Do you have any additional requests about your medical treatment?

After discussion with your physician, you may wish to consider listing particular treatments in Addition Requests field (see below) that you do or do not want in specific circumstances, such as artificially administered nutrition and hydration, intravenous antibiotics, etc. Be sure to state whether you do or do not want the particular treatment.)

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Adult Guardianship

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Primary guardian of your person (full name)

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Primary guardian of your person (relation to you, e.g., “spouse,” “friend”)

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Name of First Alternate Guardian of your person

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Relation with First Alternate Guardian of your person

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Name of Second Alternate Guardian of your person

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Relation with Second Alternate Guardian of your person

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Name of Primary Guardian of your Estate

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Relation with Primary Guardian of your Estate

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Name of First Alternate Guardian of your Estate

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Relation with First Alternate Guardian of your Estate

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Name of Second Alternate Guardian of your Estate

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Relation of Second Alternate Guardian your Estate

Minor Child Guardianship

Do you have minor Daughter(s)?

Yes

No

Number of Daughter(s)

Name of Daughter(s)

Do you have minor Son(s)?

Yes

No

Number of Son(s)

Name of Son(s)

Full name of first primary guardian - For Appointment of Guardian for Minor Child

Relation of first primary guardian to child - For Appointment of Guardian for Minor Child

Full name of second primary guardian - For Appointment of Guardian for Minor Child

Relation of second primary guardian to child - For Appointment of Guardian for Minor Child

Name the children for which you want to appoint a guardian - For Appointment of Guardian for Minor Child

Full name of first alternate guardian - For Appointment of Guardian for Minor Child

Relation of first alternate guardian to child- For Appointment of Guardian for Minor Child

Full name of second alternate guardian - For Appointment of Guardian for Minor Child

Relation of second alternate guardian to child - For Appointment of Guardian for Minor Child