21815 Oak Park Trails Drive Katy TX 77450
Tel: 281-646-0644 Fax: 281-676-3758
Date:_________________
Client Information Form (Estate Planning)
Client Information
First Name _________________________________Middle Name________________________ Family Name ______________________________
Name you prefer to be called __________________________________________________________________________________________________
Date of Birth________________________ Birthplace________________________ SSN#_________________________ DL#___________________
Current Address ________________________________________________________________________________________________________________
City ___________________________________ State____________________ Zip____________________ County________________________________
Telephone: Home________________________________ Cell________________________________ Work___________________________________
Email _____________________________________________________________________________________________________________________________
Best contact to reach you at ____________________________________________________________________________________________________
Employer _____________________________________________________ Job Title ________________________________________________________
Work Address ___________________________________________________________________________________________________________________
Where will you be storing your completed documents? ____________________________________________________________________
Marital Information
Marital Status (Married, Single, Divorced, Widowed?)_______________________________________________________________________
Name of Spouse _________________________________________________________________________________________________________________
Date of Marriage ___________________________________________ Place of Marriage _______________________________________________
Date of Divorce or Death of Spouse ___________________________________________________________________________________________
Does your spouse require estate planning at this time? _____________________________________________________________________
Do you have any children? ________________________________________ If yes, how many? _______________________________________
Please provide the names and contact information of each child:
1. Name ___________________________________________________________________ Birthdate_________________________________
Address _____________________________________________________________________________________________________________
Telephone_____________________________________ Name of other parent ____________________________________________
2. Name ___________________________________________________________________ Birthdate_________________________________
Address _____________________________________________________________________________________________________________
Telephone_____________________________________ Name of other parent ____________________________________________
3. Name ___________________________________________________________________ Birthdate_________________________________
Address _____________________________________________________________________________________________________________
Telephone_____________________________________ Name of other parent ____________________________________________
4. Name ___________________________________________________________________ Birthdate_________________________________
Address _____________________________________________________________________________________________________________
Telephone_____________________________________ Name of other parent ____________________________________________
5. Name ___________________________________________________________________ Birthdate_________________________________
Address _____________________________________________________________________________________________________________
Telephone_____________________________________ Name of other parent ____________________________________________
6. Name ___________________________________________________________________ Birthdate_________________________________
Address _____________________________________________________________________________________________________________
Telephone_____________________________________ Name of other parent ____________________________________________
7. Name ___________________________________________________________________ Birthdate_________________________________
Address _____________________________________________________________________________________________________________
Telephone_____________________________________ Name of other parent ____________________________________________
8. Name ___________________________________________________________________ Birthdate_________________________________
Address _____________________________________________________________________________________________________________
Telephone_____________________________________ Name of other parent ____________________________________________
Asset Information
Do you have any of the following assets:
⎕ Life Insurance
Value $_________________
⎕ CDs
Value $_________________
⎕ Retirement Plans Value $_________________
⎕ Brokerages
Value $_________________
⎕ Residence
⎕ Loans to Others
Value $_________________
⎕ Other Real Estate Value $_________________
⎕ Businesses
Value $_________________
⎕ Checking Accounts Value $_________________
⎕ Vehicles
Value $_________________
⎕ Savings Accounts Value $_________________
⎕ Personal Effects
Value $_________________
Value $_________________
⎕ Other Description _____________________________________________________________ Value $_________________
Do you own any real property outside the State of Texas? __________________________________________________________________
If yes, address ___________________________________________________________________________________________________________________
Describe topics you want to discuss and how you want your estate to be distributed upon your death
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Do you anticipate someone contesting the terms of your Last Will and Testament? _____________________________________
If yes, who and why _____________________________________________________________________________________________________________
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Who do you want to name as the Executor of your
estate?
Who do you want to name as the Guardian of your
minor children?
1st Executor
Name _____________________________________________________
Relation __________________________________________________
Address __________________________________________________
____________________________________________________________
Phone Number __________________________________________
1st Guardian
Name _____________________________________________________
Relation __________________________________________________
Address __________________________________________________
____________________________________________________________
Phone Number __________________________________________
2nd Executor
Name _____________________________________________________
Relation __________________________________________________
Address __________________________________________________
____________________________________________________________
Phone Number __________________________________________
2nd Guardian
Name _____________________________________________________
Relation __________________________________________________
Address __________________________________________________
____________________________________________________________
Phone Number __________________________________________
3rd Executor
Name _____________________________________________________
Relation __________________________________________________
Address __________________________________________________
____________________________________________________________
Phone Number __________________________________________
3rd Guardian
Name _____________________________________________________
Relation __________________________________________________
Address __________________________________________________
____________________________________________________________
Phone Number _________________________________________
Who do you want to name as the Trustee of your
trusts (if any)?
Who do you want to name your Agent on your
Durable Power of Attorney?
1st Trustee
Name _____________________________________________________
Relation __________________________________________________
Address __________________________________________________
____________________________________________________________
Phone Number __________________________________________
1st Agent
Name _____________________________________________________
Relation __________________________________________________
Address __________________________________________________
____________________________________________________________
Phone Number __________________________________________
2nd Trustee
Name _____________________________________________________
Relation __________________________________________________
Address __________________________________________________
____________________________________________________________
Phone Number __________________________________________
2nd Agent
Name _____________________________________________________
Relation __________________________________________________
Address __________________________________________________
____________________________________________________________
Phone Number __________________________________________
3rd Trustee
Name _____________________________________________________
Relation __________________________________________________
Address __________________________________________________
____________________________________________________________
Phone Number __________________________________________
3rd Agent
Name _____________________________________________________
Relation __________________________________________________
Address __________________________________________________
____________________________________________________________
Phone Number __________________________________________
Who do you want to name as your Agent on your
Medical Power of Attorney?
Who do you want to appoint as your Agent to
dispose of your remains?
1st Agent
Name _____________________________________________________
Relation __________________________________________________
Address __________________________________________________
____________________________________________________________
Phone Number __________________________________________
1st Agent
Name _____________________________________________________
Relation __________________________________________________
Address __________________________________________________
____________________________________________________________
Phone Number __________________________________________
2nd Agent
Name _____________________________________________________
Relation __________________________________________________
Address __________________________________________________
____________________________________________________________
Phone Number __________________________________________
2nd Agent
Name _____________________________________________________
Relation __________________________________________________
Address __________________________________________________
____________________________________________________________
Phone Number __________________________________________
3rd Agent
Name _____________________________________________________
Relation __________________________________________________
Address __________________________________________________
____________________________________________________________
Phone Number __________________________________________
3rd Agent
Name _____________________________________________________
Relation __________________________________________________
Address __________________________________________________
____________________________________________________________
Phone Number __________________________________________
Who do you want to name as your Agent on your
HIPAA Release?
Do you have specific instructions for the
disposition of your remains? If yes, please detail
below
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1st Agent
Name _____________________________________________________
Relation __________________________________________________
Address __________________________________________________
____________________________________________________________
Phone Number __________________________________________
2nd Agent
Name _____________________________________________________
Relation __________________________________________________
Address __________________________________________________
____________________________________________________________
Phone Number __________________________________________
3rd Agent
Name _____________________________________________________
Relation __________________________________________________
Address __________________________________________________
____________________________________________________________
Phone Number __________________________________________
HOW DID YOU HEAR ABOUT OUR PRACTICE?
Internet Search/LIVING Magazine (Katy)/Cinco Ranch Newsletter/Cross Creek Ranch Newsletter/Yellow
Pages/Local Directory/Referred (if you were referred please indicate by whom)
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