106 ½ N Minnesota Street
PO Box 38
New Ulm MN 56073
Telephone: (507) 354-2161
Fax: (507) 354-2160
1-866-534-2577
[email protected]
Personal Information Form
(please print in ink)
Date completed: _________________
How did you hear about us?
____ mailing ____ newspaper ____ yellow pages ____ radio ____ other _____________________
____ Previous client
__________________________________________
____ Personal referral __________________________________________________________________
Please identify other professionals with whom you work
CPA/Tax Preparer:
Phone #
Address
Company
Financial Advisor:
Phone #
Address
____
_____
Company
Stock Broker:
Phone #
Company
Address
Client #1
Name
Nickname
First
Middle Initial
Last
Birth date:
Age:
Home Address:
Gender: Male
Female SS#_________________
City:
State
Zip
Home telephone: (
)
County of Residence:
Work telephone: (
)
Email address:
Cell: (
)
Occupation:
Retired
Marital Status:
Single
Widowed
Divorced
Married If married, date of marriage_________________
First marriage? Yes___ No___
Citizenship: Are you a U.S. Citizen? Yes ____ No ____
Veteran Status:
Have you ever been in the military? Yes ___ No ___
Have you contacted your County V.A. office regarding your benefits? Yes ___ No ___
Created by The Legal Professionals PA Revision date: 8/24/2016
Client #2
Name
Nickname
First
Middle Initial
Last
Birth date
Age:
Home Address:
Gender: Male
Female SS#_________________
City:
State
Zip
Home telephone (
)
County of Residence
Work telephone (
)
Email address
Cell (
)
Occupation:
Retired
First marriage? Yes___ No___
Citizenship: Are you a U.S. Citizen? Yes ___ No ___
Veteran Status:
Have you ever been in the military? Yes____ No____
Have you contacted your County V.A. office regarding your benefits? Yes ____
No ____
1.
Child and/or Beneficiary
Name
Nickname
First
Middle Initial
Last
Relationship:
Biological Child Joint
Adopted Child Joint
Biological Child Husband
Adopted Child Husband
Biological Child Wife
Adopted Child Wife
Other:_________________________
Age
Home Address:
City:
Home telephone: (
Work telephone: (
Cell: (
)
Special Needs:
Step-child Joint
Step-child Husband
Step-child Wife
Birth date
Gender:
State
County of Residence:
Email address:
Occupation:
Educational
Marital Status of Child/Beneficiary:
Names of Child/Bene’s Children
Male
Female
Zip
)
)
Medical
Niece
Nephew
Friend
Single
Parents
Retired
Financial
Divorced
Ages
Widowed
Married Spouse's Name
Special Needs
Created by The Legal Professionals PA
2.
Child and/or Beneficiary
Name
Nickname
First
Middle Initial
Last
Relationship:
Biological Child Joint
Adopted Child Joint
Biological Child Husband
Adopted Child Husband
Biological Child Wife
Adopted Child Wife
Other:_________________________
Age
Home Address:
City:
Home telephone: (
Work telephone: (
Cell: (
)
Special Needs:
Birth date
Niece
Nephew
Friend
Gender:
State
Male
Female
Zip
)
)
County of Residence:
Email address:
Occupation:
Medical
Educational
Marital Status of Child/Beneficiary:
Names of Child/Bene’s Children
3.
Step-child Joint
Step-child Husband
Step-child Wife
Single
Retired
Financial
Divorced
Parents
Widowed
Married Spouse's Name
Ages
Special Needs
Child and/or Beneficiary
Name
Nickname
First
Middle Initial
Last
Relationship:
Biological Child Joint
Adopted Child Joint
Biological Child Husband
Adopted Child Husband
Biological Child Wife
Adopted Child Wife
Other:_________________________
Age
Home Address:
City:
Home telephone: (
Step-child Joint
Step-child Husband
Step-child Wife
Birth date
Gender:
State
)
Niece
Nephew
Friend
Male
Female
Zip
County of Residence:
Created by The Legal Professionals PA
Work telephone: (
Cell: (
)
Special Needs:
)
Email address:
Occupation:
Medical
Educational
Marital Status of Child/Beneficiary:
Names of Child/Bene’s Children
4.
Single
Retired
Financial
Divorced
Parents
Widowed
Married Spouse's Name
Ages
Special Needs
Child and/or Beneficiary
Name
Nickname
First
Middle Initial
Last
Relationship:
Biological Child Joint
Adopted Child Joint
Biological Child Husband
Adopted Child Husband
Biological Child Wife
Adopted Child Wife
Other:_________________________
Age
Home Address:
City:
Home telephone: (
Work telephone: (
Cell: (
)
Special Needs:
Step-child Joint
Step-child Husband
Step-child Wife
Birth date
Gender:
State
County of Residence:
Email address:
Occupation:
Educational
Marital Status of Child/Beneficiary:
Names of Child/Bene’s Children
Male
Female
Zip
)
)
Medical
Niece
Nephew
Friend
Single
Parents
Retired
Financial
Divorced
Ages
Widowed
Married Spouse's Name
Special Needs
Created by The Legal Professionals PA
5.
Child and/or Beneficiary
Name
Nickname
First
Middle Initial
Last
Relationship:
Biological Child Joint
Adopted Child Joint
Biological Child Husband
Adopted Child Husband
Biological Child Wife
Adopted Child Wife
Other:_________________________
Age
Home Address:
City:
Home telephone: (
Work telephone: (
Cell: (
)
Special Needs:
Step-child Joint
Step-child Husband
Step-child Wife
Niece
Nephew
Friend
Birth date
Gender:
State
County of Residence:
Email address:
Occupation:
Educational
Marital Status of Child/Beneficiary:
Names of Child/Bene’s Children
Female
Zip
)
)
Medical
Male
Single
Parents
Retired
Financial
Divorced
Widowed
Married Spouse's Name
Ages
Special Needs
OTHER DEPENDENTS - Friends or relatives who are dependents. (Use Full Legal Name)
Name
Relationship
Special Needs
Created by The Legal Professionals PA
ASSETS
JOINT
CLIENT
SPOUSE
1. Cash Accounts
$
$
$
2. Investment Accounts
$
$
$
3.
4.
5.
6.
$
$
$
$
$
$
$
$
$
$
$
$
7. Pension Plans
$
$
$
8. Life Insurance Policies
$
$
$
9. Annuities
$
$
$
10.
11.
12.
13.
14.
15.
16.
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
17. Other Assets (coop equities, etc.):
$
$
$
TOTAL ASSETS
$
$
$
Stocks
Bonds
Personal Effects
Retirements Plans
Monies Owed to You
Partnership & LLC’s Interests
Corporate Business Interests
Sole Proprietorship Interests
Oil, Gas, and Mineral Interests
Anticipated Inheritance, Gift, or Judgment
Real Property
Created by The Legal Professionals PA
LIABILITIES
1.
2.
3.
4.
5.
6.
JOINT
Loans payable
Accounts payable
Real estate mortgages payable
Loans against life insurance
Unpaid taxes
Other obligations
TOTAL LIABILITIES
NET ESTATE
CLIENT
SPOUSE
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
OTHER INFORMATION NEEDED / REQUIRED:
1. Current Documents: i.e. Will(s), Trust(s), Health Care Directive(s), Power of Attorney, etc.
2. Business Ownership: Do you and/or your spouse, if any, own any interest in a business? Yes _____
No _____
If so, please provide the formal name of your business: __________________________________________
Please place an “x” by the type of business you own:
Sole Proprietorship _____
LLC _____
Partnership _____
Corporation _____
3. Genetic Material:
a) Do you or your spouse, if any, have any stored genetic material (sperm, eggs, and/or embryos)?
Yes _____ No _____
If so, for each type of genetic material stored, please state:
What type of genetic material is stored? _____________________________________________________________
Whose genetic material is it? ________________________________________________________________________
Please list the name and address of the storage facility(ies):_________________________________________________
__________________________________________________
___________________________________________________
b) What is your intended use or other disposition of all stored genetic material at this time? _____________________________
____________________________________________________________________________________________________
Created by The Legal Professionals PA