(239) 317-3116
Safe Harbor Law Firm

Safe Harbor Law Firm

Estate Planning and Elder Law. Protecting Families for Generations

Facebook Twitter Linkedin
  • Home
  • About Us
  • Practice Areas
    • Estate Planning
    • Elder Law/Medicaid Planning
    • Probate/Trust Administration
    • Asset Protection
  • Workshops
  • Blog
  • Contact Us

Personal and Financial Information Form

Step 1 of 7

14%

CLIENT PERSONAL INFORMATION

Name(Required)
Date of Birth(Required)
Citizenship(Required)
Employment Status(Required)
Marital Status(Required)
Date of Marriage
Marriage

SPOUSE'S PERSONAL INFORMATION (if applicable)

Spouse's Name
Date of Birth
Date of Death (if applicable)
Citizenship
Employment Status
Marriage

CONTACT INFORMATION

Your Address(Required)
Which number(s) would you prefer to be contacted at?(Required)
Select all that apply

CONTACTS

Financial Advisor Name
Accountant Name
Are you or your spouse a veteran?(Required)
If yes, is it you or your spouse(Required)

EXISTING ESTATE PLANNING

Do You Have a Will?(Required)
Does Your Spouse Have a Will?
Do You Have a Trust?(Required)
Does Your Spouse Have a Trust?
Do You Have a Power of Attorney?(Required)
Does Your Spouse Have a Power of Attorney?
Do You Have a Health Care Proxy?(Required)
Does Your Spouse Have a Health Care Proxy?
Do You Have a Living Will?(Required)
Does Your Spouse Have a Living Will?
Do You Have Long-Term Care Insurance?(Required)
Does Your Spouse Have Long-Term Care Insurance?
Have you transferred or gifted away assets away in the last 60 months?(Required)

HEALTH STATUS

Your health status plays an important role in the designing of an estate plan best suited for you and your loved ones.
Your Current Health Status(Required)
Your Spouse's Current Health Status

PERSONAL/FAMILY INFORMATION

Do you have children?(Required)
Please specify:
Do you have grandchildren?(Required)
Does your spouse have children?
Please specify:
Does your spouse have grandchildren?

CHILDREN and GRANDCHILDREN

Click the button to add information about your children and grandchildren.
Name Gender Date of Birth Actions
     
  • Edit
  • Delete
There are no Children/Grandchildren.

Maximum number of children/grandchildren reached.

ANY OTHER PERSON OR ENTITY NAMED IN YOUR PLAN

Siblings, entities like churches, charities, executors, trustees or any other named person
Click the button to add information about any other people or entities named in your plan.
Actions
  • Edit
  • Delete
There are no Entries.

Maximum number of entries reached.

YOUR MONTHLY INCOME

Calculated field

YOUR SPOUSE'S MONTHLY INCOME

Calculated field

JOINT MONTHLY INCOME

Calculated field

TOTAL MONTHLY INCOME

Calculated fields

YOUR ASSET INFORMATION

Calculated field

YOUR SPOUSE'S ASSET INFORMATION

Calculated field

JOINT ASSET INFORMATION

Calculated field

TOTAL ASSETS

Calculated fields

OTHER ASSETS NOT LISTED

Other Assets
Type
Owner(s)
Value($)
 
Click the plus button to add additional lines.
Enter the total amount of other assets

YOUR LIABILITIES

Calculated field

YOUR SPOUSE'S LIABILITIES

Calculated field

JOINT LIABILITIES

Calculated field

TOTAL LIABILITIES

Calculated fields

YOUR BUSINESS INTERESTS

Calculated field

YOUR SPOUSE'S BUSINESS INTERESTS

Calculated field

JOINT BUSINESS INTERESTS

Calculated field

TOTAL BUSINESS INTERESTS

Calculated fields
This field is for validation purposes and should be left unchanged.

Call Today

(239) 317-3116

Facebook Twitter Linkedin
Lawyers with Purpose Member

Navigation

  • Home
  • About Us
  • Practice Areas
  • Workshops
  • Blog
  • Contact Us

Practice Areas

  • Estate Planning
  • Elder Law/Medicaid Planning
  • Probate/Trust Administration
  • Asset Protection
Shopping Basket