Office: 2751 Buford Hwy NE Atlanta, Georgia 30324 Phone: (404) 736-6066 Fax: (404) 736-6057 AtlantaLegalRemedy.com Mailing Address: 2480 Briarcliff Road NE, Suite 6-345, Atlanta, Georgia 30329 ESTATE PLANNING INTAKE QUESTIONNAIRE - INDIVIDUAL PERSONAL INFORMATION Zip: Ext.: State: Work Phone: Email: Is call needed before fax sent?: Social Security Number: Marital Status: Date of Divorce: Your Complete Legal Name: Your Present Address: City: Home Phone: Cell Phone: Fax: Date of Birth: Drivers License Number: Date of Marriage: Present Health: Safe Deposit Box(es) Locations: Name on Box: Name on Box: Name on Box: Other Residences: Prior Residences: Today’s Date: EMPLOYMENT/BUSINESS Name of Business/Employment: Business Address: Phone: Type of Business: Form of Ownership (sole proprietor, partner, limited partner, corporation, other): Please complete the following form. If you are unsure what to put or whether a question applies to your situation, you may leave it blank. Additionally, when giving information about a minor, please provide the email and phone number for the child’s guardian instead of the child. Yes No Siedentopf Law 1 of 12 Rev.02..18
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Estate Planning Intake Form - INDIVIDUAL · Estate Planning Intake Form - INDIVIDUAL Created Date: 2/5/2018 2:26:01 PM ...
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Form of Ownership (sole proprietor, partner, limited partner, corporation, other):
Please complete the following form. If you are unsure what to put or whether a question applies to your situation, you may leave it blank. Additionally, when giving information about a minor, please provide the email and phone number for the child’s guardian instead of the child.
Yes No
Siedentopf Law 1 of 12 Rev.02..18
ESTIMATED INCOME FOR CURRENT YEAR
Base Salary ______________________
Bonus and Other Compensation ______________________
Taxable Dividends and Interest ______________________
Tax-Exempt Income ______________________
Capital Gains or Losses ______________________
Other Income (Specify) ______________________
Total ______________________
MILITARY SERVICE
Your branch of service: ____________________________________
Your dates of service: ____________________________________
Your rank: ____________________________________
Your service number: ____________________________________
Date of discharge: ____________________________________
Your service-connected disabilities (%): ____________________________________
Your pension and retirement information is located: ____________________________________
Name on Account: Account Type: Bank/Institution: Number: Maturity Dates:
Name on Account: Account Type: Bank/Institution: Number: Maturity Dates:
CASH, BANK ACCOUNTS, CERTIFICATES OF DEPOSIT INFORMATION
Account Type:
Number: Maturity Dates:
Account Type:
Name on Account:
Bank/Institution:
Name on Account:
Bank/Institution: Number: Maturity Dates:
Siedentopf Law 2 of 12 Rev.02..18
REAL PROPERTY INFORMATION (Include Residential, Business, Recreational, Rental, Timeshare, Foreign Real Estate, Other)
Type:
Name(s) on Title: Title Held By:
Assessed Value: Insurance:
Type:
Name(s) on Title: Title Held By:
Assessed Value: Insurance:
Type:
Name(s) on Title: Title Held By:
Assessed Value: Insurance:
SECURITIES, STOCKS, BONDS, GOVERNMENT BONDS INFORMATION
Date of Death Value:
Number of Shares:
Certificate Numbers:
Date of Death Value:
Title:
Company Name:
Type of Stock (Common or Preferred):
Title:
Company Name:
Type of Stock (Common or Preferred):
Number of Shares:
Certificate Numbers:
Accrued Interest:
U.S. SAVINGS BONDS
Title:
Date of Issue:
Title:
Date of Issue: Accrued Interest:
Serial Number:
Date of Death Value:
Serial Number:
Date of Death Value:
Serial Number:
Bond Type:
Face Amount:
Date of Issue:
Maturity Date:
Date of Death Value: Face Amount:
BONDS
Title:
Issuer:
Interest Note:
Value at Maturity:
STOCKS
Siedentopf Law 3 of 12 Rev.02..18
TANGIBLE PERSONAL PROPERTY
MOTOR VEHICLES 1 2 3
Make, Model, Year ___________________ ___________________ ___________________ ___________________ Titleholder
SPECIFIC BEQUESTS (contained in Last Will & Testament)
WISHES REGARDING DIVISION OF PROPERTY AND ASSETS
I agree to submitting this form via email. I understand that if I do not wish to send via email, I may mail it to: 2480 Briarcliff Road NE,Suite 6-345,Atlanta,Georgia 30329, or call the office at (404)736-6066 to arrange for a secure transfer.