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Client Intake Form
TWDAdmin
2019-01-22T22:42:37+00:00
Client Intake Form
Step
1
of
7
14%
Trust Name:
Most clients prefer either: The Jones Family or The John and Mary Jones Living Trust.
TD Date:
Rstmt:
Section A: Client Personal Information
Number of Clients
1
2
Client 1 Name
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Middle
Last
Suffix
Date of Birth
Month
Day
Year
Email
Marital Status
Married
Divorced
Widowed
Single
US Citizen
Yes
No
Primary Phone #
Secondary Phone # (Optional)
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
County
Client 2 Name
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Middle
Last
Suffix
Social Security Number
Date of Birth
Month
Day
Year
Email
Marital Status
Married
Divorced
Widowed
Single
US Citizen
Yes
No
Primary Phone #
Secondary Phone # (Optional)
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
County
Section B: Children or Beneficiaries
Parent Codes
B
= Natural Child of Both Spouses |
1
= Natural Child of Client 1 |
2
= Natural Child of Client 2
A1
= Adopted by Client 1 |
A2
= Adopted by Client 2 |
DC
= Deceased with Children |
DN
= Deceased with No Children
Number of Children / Beneficiaries
1
2
3
4
Full Name
Date of Birth
Month
Day
Year
Percentage of Estate
Parent Code
Check All That Apply
B
1
2
A1
A2
DC
DN
Full Name
Date of Birth
Month
Day
Year
Percentage of Estate
Parent Code
Check All That Apply
B
1
2
A1
A2
DC
DN
Full Name
Date of Birth
Month
Day
Year
Percentage of Estate
Parent Code
Check All That Apply
B
1
2
A1
A2
DC
DN
Full Name
Date of Birth
Month
Day
Year
Percentage of Estate
Parent Code
Check All That Apply
B
1
2
A1
A2
DC
DN
Handicapped
Are any of your children or named beneficiaries handicapped or do they receive SSI benefits?
Yes
No
Alternate Distribution
If a beneficiary predeceases their distribution of the estate, distribute as follows:
Equally among other surviving beneficiaries
Equally among the children of the deceased beneficiary
Other
Name
Section C: Trustee(S)
Client 1 to serve as Original Trustee
Client(s) to serve as Original Trustee
Client 1
Client 2
Successor Trustee(s) & Executors for Four - Over Will
Serve Order
The Successor Trustees are to serve in order listed
The Successor Trustees are to serve together
Name
Phone
Name
Phone
Name
Phone
Name
Phone
Section D: Durable Power of Attourney for Asset Management
Power of Attorney(s) for Client 1
Name
Spouse
Yes
No
I or IC
I
IC
Name
I or IC
I
IC
Name
I or IC
I
IC
POA(s) to serve in order listed
POA(s) to serve together
Power of Attorney(s) for Client 2
Name
Spouse
Yes
No
I or IC
I
IC
Name
I or IC
I
IC
Name
I or IC
I
IC
POA(s) to serve in order listed
POA(s) to serve together
Section E: Durable Power of Attorney for Health Care
Power of Attorney(s) for Client 1
Name
Phone
Spouse
Yes
No
Name
Phone
Name
Phone
POA(s) to serve in order listed
POA(s) to serve together
Burial
Cremation
Power of Attorney(s) for Client 2
Name
Phone
Spouse
Yes
No
Name
Phone
Name
Phone
POA(s) to serve in order listed
POA(s) to serve together
Burial
Cremation
ACKNOWLEDGMENT:
I/We have read the information on this application and confirm that it is true and correct.
Client 1 Signature
Date
Month
Day
Year
Client 2 Signature
Date
Month
Day
Year
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.
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