Client Intake Form

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1. General Client Information

Client 1
Name
First Name Middle Name/Initial Last Name Other Names Used
Age
Gender
Preferred Pronoun
Address
Address City, State Zip
Cell Phone
Home Phone
Email Address
Preferred Contact Type
Health Status
US Citizen
US Veteran
First Marriage
- Yes
- No
If no, prior marriage terminated by
- Death
- Divorce

Client 2
Name
First Name Middle Name/Initial Last Name Other Names Used
Age
Gender
Preferred Pronoun
Address
Address City, State Zip
Cell Phone
Home Phone
Email Address
Preferred Contact Type
Health Status
US Citizen
US Veteran
First Marriage
- Yes
- No
If no, prior marriage terminated by
- Death
- Divorce

2. How did you hear about Albanese Law? Referral Name/Source

Personal Referral
Professional Referral (attorney, accountany, other professional, etc.)
Other,please specify (Website, Google, etc.)
Family or friends you would like us to contcat?

3. Employment, Income, Medical Information (if retired please list last/former employer)

Client 1
Retired
- Yes
- No
Occupation
Employer
Work Email
Employment Income
Pension Income
Social Security Retirement Benefits
Other Income (trust, disability, rental, etc.)
Special Classification
- SSI
- SSDI
- MassHealth
Health Insurance Plan Name

Client 2
Retired
- Yes
- No
Occupation
Employer
Work Email
Employment Income
Pension Income
Social Security Retirement Benefits
Other Income (trust, disability, rental, etc.)
Special Classification
- SSI
- SSDI
- MassHealth
Health Insurance Plan Name

4. Family Information – a. Children

Child 1
Name
Child of
- This Marriage
- Prior Marriage
Age
Gender/Pronoun
Occupation
Address
Address City, State Zip
Cell Phone
Home Phone
Email Address
Health Status
Marital Status
Spouse Name
Died leaving children
- Yes
- No
Special Needs or disabled
- Yes
- No
Special Classification
- SSI
- SSDI
- MassHealth
Grandchild Name/Age

Child 2
Name
Child of
- This Marriage
- Prior Marriage
Age
Gender/Pronoun
Occupation
Address
Address City, State Zip
Cell Phone
Home Phone
Email Address
Health Status
Marital Status
Spouse Name
Died leaving children
- Yes
- No
Special Needs or disabled
- Yes
- No
Special Classification
- SSI
- SSDI
- MassHealth
Grandchild Name/Age

4. Family Information – a. Children

Child 3
Name
Child of
- This Marriage
- Prior Marriage
Age
Gender/Pronoun
Occupation
Address
Address City, State Zip
Cell Phone
Home Phone
Email Address
Health Status
Marital Status
Spouse Name
Died leaving children
- Yes
- No
Special Needs or disabled
- Yes
- No
Special Classification
- SSI
- SSDI
- MassHealth
Grandchild Name/Age

Child 4
Name
Child of
- This Marriage
- Prior Marriage
Age
Gender/Pronoun
Occupation
Address
Address City, State Zip
Cell Phone
Home Phone
Email Address
Health Status
Marital Status
Spouse Name
Died leaving children
- Yes
- No
Special Needs or disabled
- Yes
- No
Special Classification
- SSI
- SSDI
- MassHealth
Grandchild Name/Age

4. Family Information – a. Children

Child 5
Name
Child of
- This Marriage
- Prior Marriage
Age
Gender/Pronoun
Occupation
Address
Address City, State Zip
Cell Phone
Home Phone
Email Address
Health Status
Marital Status
Spouse Name
Died leaving children
- Yes
- No
Special Needs or disabled
- Yes
- No
Special Classification
- SSI
- SSDI
- MassHealth
Grandchild Name/Age

Child 6
Name
Child of
- This Marriage
- Prior Marriage
Age
Gender/Pronoun
Occupation
Address
Address City, State Zip
Cell Phone
Home Phone
Email Address
Health Status
Marital Status
Spouse Name
Died leaving children
- Yes
- No
Special Needs or disabled
- Yes
- No
Special Classification
- SSI
- SSDI
- MassHealth
Grandchild Name/Age

4. Family Information – b. Partners/Significant Others/Parents/Siblings/Other Significant Relatives

Client 1
Relationship
Name
Age
Gender/Pronoun
Occupation
Address
Address City, State Zip

Client 2
Relationship
Name
Age
Gender/Pronoun
Occupation
Address
Address City, State Zip

5. Other Professional Advisors: Accountant, Investment, Insurance, Attorney, etc.

Client 1
Type
Name
Company
Contact Phone
Email Address
Ok to Contact?
- Yes
- No

Client 2
Type
Name
Company
Contact Phone
Email Address
Ok to Contact?
- Yes
- No

6. Financial Information – a. Real Estate: Primary, Vacation, Timeshare, Land, Rental

Client 1
Type
Address
Address City, State Zip
Tax Exemption for Primary Residence?
- Yes
- No
Ownership
- Yes
- No
- Joint
Value
Outstanding Mortgage
Outstanding Line of Credit

Client 2
Type
Address
Address City, State Zip
Tax Exemption for Primary Residence?
- Yes
- No
Ownership
- Yes
- No
- Joint
Value
Outstanding Mortgage
Outstanding Line of Credit

6. Financial Information – b. Cash: Checking, Savings, CD

Client 1
Type
Name(s) on Account
Institution Name
Balance
Beneficiary(ies)

Client 2
Type
Name(s) on Account
Institution Name
Balance
Beneficiary(ies)

6. Financial Information – c. Investments (non-retirement): Mutual Fund, Investment Account, Stocks, Bonds)

Client 1
Type
Name(s) on Account
Institution Name
Balance
Beneficiary(ies)

Client 2
Type
Name(s) on Account
Institution Name
Balance
Beneficiary(ies)

6. Financial Information – d. IRA Accounts: Tradition, Roth, SEP, Rollover

Client 1
Type
Owner($)
Institution Name
Value
Original Owner
- Orignal Owner
- Inherited
Inherited Date of Death
Primary Beneficiary(ies)/%
Contingent Beneficiary(ies)/%

Client 2
Type
Owner($)
Institution Name
Value
Original Owner
- Orignal Owner
- Inherited
Inherited Date of Death
Primary Beneficiary(ies)/%
Contingent Beneficiary(ies)/%

6. Financial Information – e. Retirement: Pension, 401(K), Profit Sharing, 403(B), 457(B)

Client 1
Type
Owner($)
Institution Name
Value
Primary Beneficiary(ies)/%
Contingent Beneficiary(ies)/%

Client 2
Type
Owner($)
Institution Name
Value
Primary Beneficiary(ies)/%
Contingent Beneficiary(ies)/%

6. Financial Information – f. Annuities

Annuity 1
Owner($)
Institution Name
Value
Qualified
- Qualified
- Non-Qualified
Primary Beneficiary(ies)/%
Contingent Beneficiary(ies)/%

Annuity 2
Owner($)
Institution Name
Value
Qualified
- Qualified
- Non-Qualified
Primary Beneficiary(ies)/%
Contingent Beneficiary(ies)/%

Annuity 3
Owner($)
Institution Name
Value
Qualified
- Qualified
- Non-Qualified
Primary Beneficiary(ies)/%
Contingent Beneficiary(ies)/%

Annuity 4
Owner($)
Institution Name
Value
Qualified
- Qualified
- Non-Qualified
Primary Beneficiary(ies)/%
Contingent Beneficiary(ies)/%

Annuity 5
Owner($)
Institution Name
Value
Qualified
- Qualified
- Non-Qualified
Primary Beneficiary(ies)/%
Contingent Beneficiary(ies)/%

Annuity 6
Owner($)
Institution Name
Value
Qualified
- Qualified
- Non-Qualified
Primary Beneficiary(ies)/%
Contingent Beneficiary(ies)/%

6. Financial Information – g. UTMA, UGMA, 529 Accounts

Client 1
Type
Owner($)
Institution Name
Value
Primary Beneficiary

Client 2
Type
Owner($)
Institution Name
Value
Primary Beneficiary

6. Financial Information – h. Tangible Personal Property (automobiles, collections, jewelry, and other personal items of value)

Owner/Description And Value
Owner/Description And Value
Owner/Description Value

6. Financial Information – i. Other (specify)

Description (owner/held in the name of, institution/account number) And Value
Description (owner/held in the name of, institution/account number) And Value
Description (owner/held in the name of, institution/account number) Value

7. Liabilities

Client 1
Car Loan(s)
Credit Card(s)
Line(s) of Credit

Client 2
Car Loan(s)
Credit Card(s)
Line(s) of Credit

Joint
Car Loan(s)
Credit Card(s)
Line(s) of Credit

8. Life Insurance

Client 1
Type
- Term
- Whole Life
Owner
Insured
Beneficiary
Contingent Beneficiary
Death Benefit
Face Value
Cash Value
Company
Email Address
Health Status
Marital Status

Client 2
Type
- Term
- Whole Life
Owner
Insured
Beneficiary
Contingent Beneficiary
Death Benefit
Face Value
Cash Value
Company
Email Address
Health Status
Marital Status

9. Business Interests: Sole Proprietorship, Partnership, Limited Liability Company (LLC), Limited Liability Partnership (LLP), C Corp, Sub-S Corp

Client 1
Business/DBA Name
Address
Address City, State ZIP
Date of Formation
State of Formation
Type of Business
- Sole Proprietorship
- Partnership
- LLC
- LLP
- C Crop
- Sub-S Crop
Description of Business
Do you have a Buy-Sell Agreement?
- Yes
- No
Do you have life insurance funding this agreement?
- Yes
- No
Fiscal Period Ending
Accountant’s Name
Accountant’s Company
Accountant’s Address
Accountant’s City, State ZIP
Accountant’s Phone
Accountant’s Email Address
Business Value
Name of Business Owner($) And Age And % of Ownership
Name of Business Owner($) And Age And % of Ownership
Name of Business Owner($) Age % of Ownership
Key Personnel And Title
Key Personnel And Title
Key Personnel Title

Client 2
Business/DBA Name
Address
Address City, State ZIP
Date of Formation
State of Formation
Type of Business
- Sole Proprietorship
- Partnership
- LLC
- LLP
- C Crop
- Sub-S Crop
Description of Business
Do you have a Buy-Sell Agreement?
- Yes
- No
Do you have life insurance funding this agreement?
- Yes
- No
Fiscal Period Ending
Accountant’s Name
Accountant’s Company
Accountant’s Address
Accountant’s City, State ZIP
Accountant’s Phone
Accountant’s Email Address
Business Value
Name of Business Owner($) And Age And % of Ownership
Name of Business Owner($) And Age And % of Ownership
Name of Business Owner($) Age % of Ownership
Key Personnel And Title
Key Personnel And Title
Key Personnel Title

10. Other Information - a. Existing Legal Documents

Client 1
Do you have a Will?
- Yes
- No
Do you have a Health Care Proxy?
- Yes
- No
Do you have a Living Will?
- Yes
- No
Do you have a Revocable Trust?
- Yes
- No
Do you have a Power of Attorney?
- Yes
- No
Do you have any Realty Trusts?
- Yes
- No
If married, do you have: (Please provide copies if applicable)
A Pre-Marital Agreement?
- Yes
- No
A Post-Nuptial Agreement?
- Yes
- No
If divorced/single, do you have: (Please provide copies if applicable)
A Divorce Agreement?
- Yes
- No
A continuing Child Support obligation?
- Yes
- No
A continuing Alimony obligation?
- Yes
- No
An obligation to maintain Life Insurance?
- Yes
- No
Other obligations?
- Yes
- No

Client 2
Do you have a Will?
- Yes
- No
Do you have a Health Care Proxy?
- Yes
- No
Do you have a Living Will?
- Yes
- No
Do you have a Revocable Trust?
- Yes
- No
Do you have a Power of Attorney?
- Yes
- No
Do you have any Realty Trusts?
- Yes
- No
If married, do you have: (Please provide copies if applicable)
A Pre-Marital Agreement?
- Yes
- No
A Post-Nuptial Agreement?
- Yes
- No
If divorced/single, do you have: (Please provide copies if applicable)
A Divorce Agreement?
- Yes
- No
A continuing Child Support obligation?
- Yes
- No
A continuing Alimony obligation?
- Yes
- No
An obligation to maintain Life Insurance?
- Yes
- No
Other obligations?
- Yes
- No

10. Other Information - b. Safe Deposit Box/Storage Facility

Client 1
Do you have a Safe Deposit Box?
- Yes
- No
Location

Client 2
Do you have a Safe Deposit Box?
- Yes
- No
Location

10. Other Information - c. Gifts and Inheritances

Client 1
Do you expect any significant gifts or inheritances?
- Yes
- No
If yes, from whom and the approximate size:
Are you currently the beneficiary of a Trust created by someone else?
- Yes
- No
Have you ever filed a gift tax return?
- Yes
- No

Client 2
Do you expect any significant gifts or inheritances?
- Yes
- No
If yes, from whom and the approximate size:
Are you currently the beneficiary of a Trust created by someone else?
- Yes
- No
Have you ever filed a gift tax return?
- Yes
- No

10. Other Information - d. Long Term Care Insurance

Client 1
Do you have Long Term Care Insurance? If yes, please provide a copy.
- Yes
- No

Client 2
Do you have Long Term Care Insurance? If yes, please provide a copy.
- Yes
- No

10. Other Information - e. Pets

Client 1
Do you have any pets?
- Yes
- No
Number and type of pets:
Do you want to provide for your pets in your estate plan?
- Yes
- No

Client 2
Do you have any pets?
- Yes
- No
Number and type of pets:
Do you want to provide for your pets in your estate plan?
- Yes
- No

10. Other Information - f. Digital Assets

Client 1
On-line Business Accounts, including online revenue streams?
- Yes
- No
Domain Name Hosting and Web Hosting?
- Yes
- No
On-line File Sharing and File Storage Accounts?
- Yes
- No
Financial and E-Commerce Websites?
- Yes
- No
Social Media and Networking Websites?
- Yes
- No
Email Accounts?
- Yes
- No
Computers and other Digital Devices?
- Yes
- No
Bitcoin or other Cryptocurrency?
- Yes
- No

Client 2
On-line Business Accounts, including online revenue streams?
- Yes
- No
Domain Name Hosting and Web Hosting?
- Yes
- No
On-line File Sharing and File Storage Accounts?
- Yes
- No
Financial and E-Commerce Websites?
- Yes
- No
Social Media and Networking Websites?
- Yes
- No
Email Accounts?
- Yes
- No
Computers and other Digital Devices?
- Yes
- No
Bitcoin or other Cryptocurrency?
- Yes
- No

10. Other Information - g. Unique Assets (antique cars, wine collections, artwork, etc.)

10. Other Information - h. Post-Death Instructions

Client 1
Do you own a burial plot?
- Yes
- No
Do you have specific burial/cremation/funeral instructions you would like to include in your estate plan?
- Yes
- No

Client 2
Do you own a burial plot?
- Yes
- No
Do you have specific burial/cremation/funeral instructions you would like to include in your estate plan?
- Yes
- No

10. Other Information - i. Copyrights/Trademarks/Patents

Client 1
Do you own or hold any copyrights, trademarks, or patents?
- Yes
- No
Details

Client 2
Do you own or hold any copyrights, trademarks, or patents?
- Yes
- No
Details

10. Other Information - j. Lawsuits/Judgements

Client 1
Are you currently party to a pending lawsuit?
- Yes
- No
Do you anticipate being a party to a lawsuit in the near future?
- Yes
- No
Is there an outstanding judgement against you?
- Yes
- No
Do you have liability concerns?
- Yes
- No
Do you anticipate filing for bankruptcy in the near future?
- Yes
- No

Client 2
Are you currently party to a pending lawsuit?
- Yes
- No
Do you anticipate being a party to a lawsuit in the near future?
- Yes
- No
Is there an outstanding judgement against you?
- Yes
- No
Do you have liability concerns?
- Yes
- No
Do you anticipate filing for bankruptcy in the near future?
- Yes
- No

11.Planning Goals

Please rate the following with respect to how important they are to you: H=High Concern S=Some Concern L=Low Concern N/A=No Concern or Not Applicable

Description of Concern or Goal
Desire to get affairs in order and create a comprehensive plan to manage affairs in case of death or disability.
Level of Concern
- H
- S
- N/A
Provide for and protect spouse or significant other.
Level of Concern
- H
- S
- N/A
Provide for and protect children.
Level of Concern
- H
- S
- N/A
Disinherit a family member.
Level of Concern
- H
- S
- N/A
Provide for charities.
Level of Concern
- H
- S
- N/A
Plan for the transfer of a family business.
Level of Concern
- H
- S
- N/A
Avoid or reduce estate taxes.
Level of Concern
- H
- S
- N/A
Avoid Probate/reduce administration costs at death.
Level of Concern
- H
- S
- N/A
Avoid Will contests or other disputes at death.
Level of Concern
- H
- S
- N/A
Avoid involvement of the Probate Court in case of incapacity.
Level of Concern
- H
- S
- N/A
Protest assets from lawsuits or creditors.
Level of Concern
- H
- S
- N/A
Preserve your privacy in case of incapacity or at time of death from business competitors, predators, dishonest persons, and curiosity seakers.
Level of Concern
- H
- S
- N/A
Plan for a child or grandchild with disabilities or special needs, such as medical or learning disabilities.
Level of Concern
- H
- S
- N/A
Protect children’$ inheritance from the possibility of failed marriage or other creditors.
Level of Concern
- H
- S
- N/A
Protect children’$ inheritance in the event of a surviving spouse’$ remarriage.
Level of Concern
- H
- S
- N/A
Provide instructions for end-of-life care.
Level of Concern
- H
- S
- N/A
Provide burial/cremation/funeral instructions.
Level of Concern
- H
- S
- N/A
Plan to pay for long-term care costs and protect assets from having to be spent on care.
Level of Concern
- H
- S
- N/A

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Client Intake Form

1. General Client Information

Client 1

Client 2

2. How did you hear about Albanese Law? Referral Name/Source

3. Employment, Income, Medical Information (if retired please list last/former employer)

Client 1

Client 2

4. Family Information – a. Children

Child 1

Child 2

4. Family Information – a. Children

Child 3

Child 4

4. Family Information – a. Children

Child 5

Child 6

4. Family Information – b. Partners/Significant Others/Parents/Siblings/Other Significant Relatives

Client 1

Client 2

5. Other Professional Advisors: Accountant, Investment, Insurance, Attorney, etc.

Client 1

Client 2

6. Financial Information – a. Real Estate: Primary, Vacation, Timeshare, Land, Rental

Client 1

Client 2

6. Financial Information – b. Cash: Checking, Savings, CD

Client 1

Client 2

6. Financial Information – c. Investments (non-retirement): Mutual Fund, Investment Account, Stocks, Bonds)

Client 1

Client 2

6. Financial Information – d. IRA Accounts: Tradition, Roth, SEP, Rollover

Client 1

Client 2

6. Financial Information – e. Retirement: Pension, 401(K), Profit Sharing, 403(B), 457(B)

Client 1

Client 2

6. Financial Information – f. Annuities

Annuity 1

Annuity 2

Annuity 3

Annuity 4

Annuity 5

Annuity 6

6. Financial Information – g. UTMA, UGMA, 529 Accounts

Client 1

Client 2

6. Financial Information – h. Tangible Personal Property (automobiles, collections, jewelry, and other personal items of value)

6. Financial Information – i. Other (specify)

7. Liabilities

Client 1

Client 2

Joint

8. Life Insurance

Client 1

Client 2

9. Business Interests: Sole Proprietorship, Partnership, Limited Liability Company (LLC), Limited Liability Partnership (LLP), C Corp, Sub-S Corp

Client 1

Client 2

10. Other Information - a. Existing Legal Documents

Client 1

Client 2

10. Other Information - b. Safe Deposit Box/Storage Facility

Client 1

Client 2

10. Other Information - c. Gifts and Inheritances

Client 1

Client 2

10. Other Information - d. Long Term Care Insurance

Client 1

Client 2

10. Other Information - e. Pets

Client 1

Client 2

10. Other Information - f. Digital Assets

Client 1

Client 2

10. Other Information - g. Unique Assets (antique cars, wine collections, artwork, etc.)

10. Other Information - h. Post-Death Instructions

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