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Intake Checklist

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General Information

MM slash DD slash YYYY
Full Legal Name (First, Middle and Last)
MM slash DD slash YYYY
Full Legal Name (First Middle and Last)
MM slash DD slash YYYY
Address*
(Client 1)
(Client 2)
(Client 1)
(Client 2)
U.S. CITIZEN?
(Client 1)
U.S. CITIZEN?
(Client 2)
ARE CLIENTS MARRIED TO EACH OTHER
CHILDREN: (First, Middle and Last Names)
Name
Date of Birth (mm/dd/yyyy)
Address & Phone Number
 
GRANDCHILDREN: (First, Middle and Last Names)
Name
Date of Birth (mm/dd/yyyy)
Names of Parents
Address & Phone Number
 
*If any grandchildren do not reside with your child, please list the grandchild’s address as well.
Do you have any deceased Children?
DO YOU PRESENTLY HAVE A TRUST?
Accepted file types: jpg, doc, png, pdf, ppt, docx, Max. file size: 32 MB.
DO YOU PRESENTLY HAVE A WILL?

YOUR ASSETS

LIFE INSURANCE:
NAME OF INSURED
AMOUNT
BENEFICIARY
COMPANY
 
Accepted file types: jpg, doc, png, pdf, ppt, docx, Max. file size: 32 MB.
DO YOU HAVE A SAFE DEPOSIT BOX?
OTHER REAL ESTATE:
Address
Value
Names of all owners
 
Accepted file types: jpg, doc, png, pdf, ppt, docx, Max. file size: 32 MB.
BANK ACCOUNTS, SAVINGS AND LOAN OR CREDIT UNIONS:
FINANCIAL INSTITUTION
TYPE
AMOUNT
OWNER
 
Any gift tax return filed
Vehicles
Vehicles
VALUE
OWNER
 
VALUE OF BUSINESS:
VALUE OF BUSINESS:
HOW OWNED?
 
Accepted file types: jpg, doc, png, pdf, ppt, docx, Max. file size: 32 MB.
If there are any IRA, pension plan or profit sharing agreements in existence for your benefit, please list the present value of the plan, whether or not you are vested and whether there is any death benefit or continuing benefit for your spouse.
PLAN
OWNER
VALUE
VESTED?
BENEFICIARY
 
Other Assets Not Previously Listed, Such as Boats, Motor Homes or Amounts Owed to You by Others, Etc.:
ASSET
VALUE
OWNER(S)
 

DEBTS

OTHER REAL ESTATE:
 
Vehicles
 
OTHER LIABILITIES INCLUDING ANY LOANS YOU MAY HAVE CO-SIGNED ON FOR OTHERS:
AMOUNT
LIEN HOLDER
SECURED ASSETS
 

LIST SIGNIFICANT DEBTS OR OBLIGATIONS OTHER THAN MORTGAGES LISTED ABOVE.

At the time of the interview you should be in a position to discuss previous marriages, if any, specific situations involving children or other beneficiaries which could affect your estate plan, any expected inheritances, and all primary beneficiaries and contingent beneficiaries, including relatives friends and charities.

If you have ever lived in a state which has a community property law, such as California, Texas, New Mexico, Arizona, Washington, Louisiana, Nevada, or Idaho, please be prepared to discuss assets brought from those states into this state.

You should be in a position to list specific assets, if any, which definitely should go to one beneficiary as opposed to any others.

Before meeting with us, please consider who will be guardian for any of your unmarried minor children and who should be personal representative of your estate and trustee of your trust. The personal representative and/or trustee could be a bank or other financial institution, your spouse, your children, a friend or a financial advisor.

Representatives

AdministratorThis person will be your trustee and/or personal representative depending on what documents we prepare for you. This person should be responsible, trustworthy and good at money management.
Name
Address
Phone Number
Alternate Administrator
Name
Address
Phone Number
Guardian:This person will be the person who your children live with if both of their parents die before the children are 18, or if your children have special needs and require a guardian as adults. This person should be loving, supportive, and should be someone who would raise your kids like you would. You may want to consider naming someone who lives in your school district or would move to your home if that is important to you.
Name
Address
Phone Number
Alternate Guardian:
Name
Address
Phone Number
Power of Attorney - Financial Agent (client 1)This person will help you manage your assets while you are alive. They may pay your bills, sign contracts for you, and change your mailing address, as examples. This person should be very trustworthy and good at managing money. This is a more personal role than the Administrator, because this is the person who will hire care givers for you, make sure your house is taken care of if you are in the hospital, etc.
Name
Address
Phone Number
Alternate Power of Attorney - Financial Agent (client 1)
Name
Address
Phone Number
Power of Attorney - Financial Agent (client 2)This person will help you manage your assets while you are alive. They may pay your bills, sign contracts for you, and change your mailing address, as examples. This person should be very trustworthy and good at managing money. This is a more personal role than the Administrator, because this is the person who will hire care givers for you, make sure your house is taken care of if you are in the hospital, etc.
Name
Address
Phone Number
Alternate Power of Attorney - Financial Agent (client 2)
Name
Address
Phone Number
Power of Attorney - Medical Agent (client 1)This person will make medical decisions for you if you are not able to make them yourself. This person should be comfortable talking with doctors and a strong advocate for you. You also need to be sure that this person will follow your wishes about life support as you make those wishes known to them.
Name
Address
Phone Number
Alternate Power of Attorney - Medical Agent (client 1)
Name
Address
Phone Number
Power of Attorney - Medical Agent (client 2)This person will make medical decisions for you if you are not able to make them yourself. This person should be comfortable talking with doctors and a strong advocate for you. You also need to be sure that this person will follow your wishes about life support as you make those wishes known to them.
Name
Address
Phone Number
Alternate Power of Attorney - Medical Agent (client 2)
Name
Address
Phone Number

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Pugh Firm

CONTACT

6905 Telegraph Road | Suite 125
Bloomfield Hills, MI, 48301
Main – (248) 644-7222 | Fax – (248) 644-7224

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