E-AFFIRMATION

Please acknowledge that you have read and agree to the disclaimer:

Yes

No

CLIENT INFORMATION

Prior Names / Other Names Known By:

Gender

Male

Female

Non-binary

Are you a US citizen?

Yes

No

Explain:

Marital Status

Married

Spouse's Name Spouse's Date of Birth US Citizen? Male or Female?

Separated

Divorced

Widowed

Single

Life Partner

Life Partner's Name Life Partner's Date of Birth Is Life Partner a US Citizen? Male or Female?

MARRIAGE DETAILS

Date of Marriage:

Have you and your spouse signed a pre- or post-marriage agreement?

Yes

No

Have you lived in any of the following states while married to each other?

(Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington, or Wisconsin)

Yes

If yes, which state?

No

PRIOR MARRIAGES

Please list additional marriages for you and/or your partner:

(Listing the name, how the marriage concluded and the date)

CHILDREN

Child #1

List Details

Full Name: Date of Birth:

Not Applicable

Child #2

Not Applicable

List Details

Full Name: Date of Birth:

Child #3

Not Applicable

List Details

Full Name: Date of Birth:

Please add any additional children in the section below:

(Include Name, Relationship, Address, Phone Number and Date of Birth)

Do you own any pets?

Yes

If yes, what animal(s):

No

CONCERNS

PROTECT YOURSELF (AND YOUR SPOUSE) FROM:

Please select all areas of high concern:

Malpractice or other creditor claimsAdult guardianship proceedings if you become incapacitatedProbate delays and costs upon your death or your spouse's deathEnd of life concerns regarding a natural death as opposed to artificially being kept aliveWho will make health care decisions if you cannotWho will handle your financial affairs if you cannotPrivacy concerns around your will and inventory being public record during probate processBeneficiaries inheriting outright and unprotected from creditors, divorce and their own spending habitsDisinheriting certain family membersProtecting a special needs beneficiary from losing government benefitsProtecting your savings from long term care costsMinimizing taxes (estate, income, capital gains)Naming a guardian for minor children and ensuring funds are available for their careProvide for a charitable organizationEnsure the continuity and proper succession plan for a business you own

_______________________________________________________

Other planning concerns or priorities?

ADVISORS (CPAS, ATTORNEYS, FINANCIAL ADVISORS, ETC.)

Advisor #1

List Details

Name: Relationship: Phone Number:

Not Applicable

Advisor #2

List Details

Name: Relationship: Phone Number:

Not Applicable

PLANNING QUESTIONS

Are you (or your spouse/partner) receiving Social Security, disability, or other government benefits?

Yes

If yes, please explain:

No

Have you ever filed federal or state gift tax returns?

Yes

No

Do you have any frozen eggs, sperm or embryos that might be used in the future?

Yes

No

Do you have an existing will or other estate planning documents?

Yes

If yes, where are the original documents currently located? Who has copies of your documents? Who prepared the documents?

No

OTHER TOPICS TO DISCUSS

Please list any other topics you want included in your estate plan or want to discuss:

INSURANCE INFORMATION

Which types of insurance policies do you own?

Please Check All That Apply

Health InsuranceLife InsuranceDisability InsuranceUmbrella/Liability InsuranceCar InsuranceProperty InsuranceLong-term Care InsuranceOther

If you have chosen other, please specify other insurance:

IMPORTANT BACKGROUND INFORMATION

Do any of your intended beneficiaries have a disability or serious health problem?

Yes

No

Do you support Charitable Organizations you would want to continue to support after your incapacity or death?

Yes

Which Charitable Organization?

No

Are you currently the Trustee or Executor of, or Receiving income from, a Trust (revocable or irrevocable) or Estate, or waiting on a distribution of an ongoing Trust or Estate Administration?

Yes

No

Have you been diagnosed with an illness such as Alzheimer's, Dementia or Similar, or have you suffered a major stroke?

Yes

No

ESTATE & ASSET INFORMATION

Do you own any interest in real estate?

(Including residence, vacation home, timeshare, vacant land, etc)

Yes

Separate or Jointly Owned? Address:

(Including City, State, and Zip Code)

Additional properties? Please list the type, address, whether it is owned jointly or separately and the approximate value for each property you own

No

Do you own checking, savings, and/or money market accounts at a bank or credit union?

Yes

List the names of the banks and approximate amounts:

No

Do you own any qualified retirement accounts?

(This includes IRA, 401k, 403b, 457b etc)

Yes

List the type of accounts, financial institutions and approximate amounts:

No

Do you own any stocks, bonds, brokerage or other investment accounts?

(This includes individual stocks and bonds, traditional investment accounts, and self-managed apps like Robinhood or Stash)

Yes

List the type, financial institution and approximate amount:

No

Do you own any valuable personal property that you want to make sure gets discussed?

(This could include valuable jewelry, art, collectibles, guns, family heirlooms, or other assets)

Yes

List the types and current value:

No

Do you own any vehicles, boats, RVs, or other similar items that have a title and must be registered with the state?

Yes

Make and model and current value:

No

Do you own any life insurance, either personally or through employer benefits?

Yes

Is it term, whole life or universal? Who is the beneficiary? What is the death benefit?

No

Do you anticipate receiving any significant gifts or inheritances from someone else's estate planning, or judgements from a pending lawsuit?

Yes

What type and estimated amount:

No

Do you own interests in any business?

Yes

Sole proprietor, LLC, Corporation or other? Percentage owned? Current value? Do you have business documents in place such as Article of Incorporation, Operating Agreement, etc:

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No

Do you own any annuities?

Yes

Financial institution and value:

No

Do you have money owed by anyone or any entity?

(This could include things like a personal loan to a friend or family member and/or an owner-financed mortgage or promissory note)

Yes

Who is the borrower, terms and amount owed:

No

Do you own any cryptocurrencies, blockchain tokens, or other valuable digital assets?

Yes

Current Value:

No

Do you owe money to anyone or any entity?

(This include debts like personal or student loans, lines of credit, credit card debt and other unsecured debt)

Yes

Types of debt and amount owed:

No

Do you own rights in any intellectual property?

(Such as copyrights, trademarks, licenses, etc)

Yes

What Type:

No

Do you own any FOREIGN ASSETS?

Yes

Where, type and value?

No

Are you the Custodian of Any Accounts for Your Children or Other Beneficiaries (such as a UTMA), or are you in control of any educational accounts (such as a 529)?

Yes

Amount:

No

Do you own any other assets we haven’t mentioned that you’d like to discuss?

Yes

Please Explain:

No

THANK YOU