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Client Intake Form

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Trust Name:*
Most clients prefer either: The Jones Family or The John and Mary Jones Living Trust.

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Section A: Client Personal Information
Number of Clients*
- 1
- 2
Client 1 Name*
Prefix First Middle Last Suffix
Date of Birth*
Month
Day
Year
Email*
Marital Status*
- Married
- Divorced
- Widowed
- Single
US Citizen*
- Yes
- No
Primary Phone #*
Secondary Phone # (Optional)*
Address*
Street Address City State ZIP Code
County*
Client 2 Name
Prefix First Middle Last Suffix
Social Security Number
Date of Birth
Month
Day
Year
Email
Marital Status
- Married
- Divorced
- Widowed
- Single
US Citizen
- Yes
- No
Primary Phone #
Secondary Phone # (Optional)
Address
Street Address Address Line 2 City State ZIP Code
County

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Section B: Children or Beneficiaries
Parent Codes
B = Natural Child of Both Spouses | 1 = Natural Child of Client 1 | 2 = Natural Child of Client 2
A1 = Adopted by Client 1 | A2 = Adopted by Client 2 | DC = Deceased with Children | DN = Deceased with No Children
Number of Children / Beneficiaries*
- Full Name
- Date of Birth
  Month
  Day
  Year
- Percentage of Estate
- Parent Code
  Check All That Apply
  - B
  - 1
  - 2
  - A1
  - A2
  - DC
  - DN
- Full Name
- Date of Birth
  Month
  Day
  Year
- Percentage of Estate
- Parent Code
  Check All That Apply
  - B
  - 1
  - 2
  - A1
  - A2
  - DC
  - DN
- Full Name
- Date of Birth
  Month
  Day
  Year
- Percentage of Estate
- Parent Code
  Check All That Apply
  - B
  - 1
  - 2
  - A1
  - A2
  - DC
  - DN
- Full Name
- Date of Birth
  Month
  Day
  Year
- Percentage of Estate
- Parent Code
  Check All That Apply
  - B
  - 1
  - 2
  - A1
  - A2
  - DC
  - DN
Handicapped*
Are any of your children or named beneficiaries handicapped or do they receive SSI benefits?
- Yes
- No
Alternate Distribution*
If a beneficiary predeceases their distribution of the estate, distribute as follows:
- Equally among other surviving beneficiaries
- Equally among the children of the deceased beneficiary
- Other
Name*

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Section C: Trustee(S)
Client 1 to serve as Original Trustee
Client(s) to serve as Original Trustee*
- Client 1
- Client 2
Successor Trustee(s) & Executors for Four - Over Will
Serve Order*
- The Successor Trustees are to serve in order listed
- The Successor Trustees are to serve together
Name
Phone
Name
Phone
Name
Phone
Name
Phone

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Section D: Durable Power of Attourney for Asset Management
Power of Attorney(s) for Client 1
- Name
- Spouse
  - Yes
  - No
- Name
- Name
- POA(s) to serve in order listed
- POA(s) to serve together
Power of Attorney(s) for Client 2
- Name
- Spouse
  - Yes
  - No
- Name
- Name

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Section E: Durable Power of Attorney for Health Care
Power of Attorney(s) for Client 1
Name*
Phone*
Spouse*
- Yes
- No
Name
Phone
Name
Phone
*
- POA(s) to serve in order listed
- POA(s) to serve together
*
- Burial
- Cremation
Power of Attorney(s) for Client 2
Name*
Phone*
Spouse*
- Yes
- No
Name
Phone
Name
Phone
*
- POA(s) to serve in order listed
- POA(s) to serve together
*
- Burial
- Cremation

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ACKNOWLEDGMENT: I/We have read the information on this application and confirm that it is true and correct.
- Date*
  Month
  Day
  Year
- Client 1 Signature*
- Date
  Month
  Day
  Year
- Client 2 Signature
- How did you hear about us?*
- CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

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Sun City, AZ 85351

Phone: 623-561-2323

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Phone: 702-835-6190

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