Intake Information Form - Wills & POAS/ESTATE PLANING Date Referred by Any reason for urgency? No Yes Details Personal Information – Client #1 Name (in full) Address Postal Code Telephone Number Email Occupation Employer Telephone Date of Birth Place of Birth Citizenship S.I.N. US Green Card? No Yes Father’s place of birth? Mother’s place of birth? Personal Information – Client #2 Name (in full) Address Postal Code Telephone Number Email Occupation Employer Telephone Date of Birth Place of Birth Citizenship S.I.N. US Green Card? No Yes Father’s place of birth? Mother’s place of birth? Marital Status – Existing Wills – Health Issues Single Married Common Law Separated Divorced Date of Marriage/Cohabitation Date ofSeparation/Divorce Widowed Engaged Separation Agreement /Court Order? No Yes Name of Deceased Spouse/Fiancé(e) Do you have a will now? Client #1 No Yes Client #2 No Yes Are you on medication that affects mood or thinking? Client #1 No Yes Client #2 No Yes Have you had a capacity-related diagnosis? Client #1 No Yes Client #2 No Yes Other Advisors Family Doctor Accountant Financial Advisor/Broker Children and Grandchildren – Use back of page to provide details if you have more than 3 children 1. Name Child of 1/2/Both Date of Birth Marital Status –circle S/M/CL/W/Sep. Address Place of Birth Occupation Telephone Notes His or her children (your grandchildren) – please indicate step-children: Name Child of 1/2/Both Date of Birth Marital Status –circle S/M/CL/W/Sep. Name Child of 1/2/Both Date of Birth Marital Status –circle S/M/CL/W/Sep. Name Child of 1/2/Both Date of Birth Marital Status –circle S/M/CL/W/Sep. 2. Name Child of 1/2/Both Date of Birth Marital Status –circle S/M/CL/W/Sep. Address Place of Birth Occupation Telephone Notes His or her children (your grandchildren) – please indicate step-children: Name Child of 1/2/Both Date of Birth Marital Status –circle S/M/CL/W/Sep. Name Child of 1/2/Both Date of Birth Marital Status –circle S/M/CL/W/Sep. Name Child of 1/2/Both Date of Birth Marital Status –circle S/M/CL/W/Sep. 3. Name Child of 1/2/Both Date of Birth Marital Status –circle S/M/CL/W/Sep. Address Place of Birth Occupation Telephone Notes His or her children (your grandchildren) – please indicate step-children: Name Child of 1/2/Both Date of Birth Marital Status –circle S/M/CL/W/Sep. Name Child of 1/2/Both Date of Birth Marital Status –circle S/M/CL/W/Sep. Name Child of 1/2/Both Date of Birth Marital Status –circle S/M/CL/W/Sep. Other Dependents or Significant Family Members ASSETS - Bank Accounts – Please give an estimate of the current balance Institution and Account Number Client #1 Client #2 Joint GICs, Stocks, Bonds, Mutual Funds, Investment Accounts Institution and Account Number Client #1 Client #2 Joint RRSPs and RRIFs Institution and Account Number Client #1 Client #2 Beneficiary Personal Property – Household furnishings, vehicles, boats, jewellry, artworks, etc. Description Appraised? Pets you wish to provide for? Loans Receivable: Does anyone owe you money? Details Pension Plans Institution Client #1 Client #2 Beneficiary Death Benefit? Life Insurance Institution and Policy Number Client #1 Client #2 Beneficiary Death Benefit Real Estate – please estimate the market value Address / Legal Description Client #1 Client #2 Joint/TIC? 1. Principal Residence Mortgage No Yes Estimated Mortgage Balance 2. Vacation Property Mortgage No Yes Estimated Mortgage Balance Date Acquired Value 3. Other Property Mortgage No Yes Estimated Mortgage Balance Date Acquired Value Business Interests Shareholder Agreement No Yes Principal Shareholders/Partners Liabilities (Other than mortgages listed above) – please estimate the current amount owing Institution/Creditor Client #1 Client #2 Joint Do you have any other assets? Please circle any that apply Notes If you are human, leave this field blank. Submit
