Ca Potential Client Intake Form

CLIENT INTAKE
PART I
FAMILY DATA
Full name:
Spouse's:
Other or former names:

Spouse's:
Home address:
Spouse's (if not the same):
If you have moved to California from another state, name the state and years of residence there and any other states
in which you have resided:
Date you moved to California:
Do you have other residences in California? Yes No
Contact information:
Home phone: Work phone: Fax:
Cell: Email:
Birth date: Birthplace:
Spouse's:
Are you a U.S. citizen? Yes No
If U.S. citizen other than by birth, state date of citizenship:
Spouse? Yes No Year of citizenship:
Do you have children (including stepchildren or foster children)? Yes No

If yes, please provide the following information for each:
Name Living? Age Birth date Married? City/State of Residence
Yes/No Yes/No
Yes/No Yes/No
Yes/No Yes/No
Yes/No Yes/No
Do you have dependents other than minor children? Yes No If so, please provide name, age, and residence.
Name: Age: Residence:
Do you have any grandchildren? Yes No If so, please provide names, ages/birth dates, and names of parents.
Name: Age: Birth date: Names of parents:
Do you presently have a will? Yes No If so, what is the date on the will?
Was it signed in California? Yes No If not, where?
Spouse presently has a will? Yes No If so, what is the date on the will?
Was it signed in California? Yes No If not, where?
Are you a beneficiary, trustee (singly or jointly), or creator of a trust? Yes No If so, what is the date of the
trust?
Is your spouse a beneficiary, trustee (singly or jointly), or creator of a trust? Yes No If so, what is the date of
the trust?
Have you signed a prenuptial or postnuptial agreement? Yes No If so, what is the date of the agreement and
name of the spouse involved?
Please provide the following information regarding your former marriages:
Name of former spouse Living? Date of Death or Divorce agreement

Yes/No
PART II
ASSETS AND LIABILITIES
ASSETS
A.Liquid assets: cash (dividends, etc.); savings accounts; checking accounts; money market accounts; certificates of
deposit; mutual funds:
Item Identification (i.e. checking account) Location (Bank Name) Value
B. Other personal property (everything except liquid assets): private corporation stocks and bonds (publicly listed);
unlisted stocks and bonds; government bills, notes, and bonds; commodities; automobiles; other vehicles
(airplanes, boats, motorcycles, recreational vehicles); precious metals; safe deposit contents; etc.
Item Identification Location Value
C. Real estate: agricultural land; boat/marina slip; cemetery plots; condominiums; cooperatives; timeshares;
duplexes; houses; mobile homes; rental properties; undeveloped land; vacation homes:
NOTE: Describe real property by listing its address or location, including the street address or apartment number or
acreage in a specified county. The legal description does not have to be provided. If the real property includes
personal items such as farm tools or animals, include them in the description, specifically listing expensive items
such as cattle or a tractor. If the items are relatively inexpensive, such as tools in a shed on otherwise vacant land,
state "along with all personal property located on the property." Subtract any mortgage or other debt owing on the
asset.
Property Address (including county) Value
D. Retirements and Life Insurance

Asset Value
PART III
NOMINATIONS
A. Guardianship: If any children are under the age of 18, list who you want appointed as their guardian if
something happens to both their parents
NAME______________________________Relationship____________________
B. Personal Representatives: Person(s) to handle your estate under your will
C. Trustees: The person(s) who will administer your trust upon the death or incapacity of both of you
D. Health care surrogate: This person makes health care decisions for you when you are incapacitated and even
allows the removal of life-sustaining treatment if no chance of recovery.
WIFE’S NOMINEE NAME __________________________________________________

ADDRESS _______________________________ Relationship____________________
HUSB NOMINEE NAME__________________________________________________

E. Durable Power of Attorney: This person makes legal and business decisions for you if you are incapacitated
or unavailable.
WIFE’S NOMINEE NAME__________________________________________________

HUSB NOMINEE NAME__________________________________________________

PART IV
DISTRIBUTIONS
List the amount and to whom you want your assets distributed after your death:
Examples – “in equal shares to our children” or “to remain in trust until children reach the age of 23” or “to remain
in trust with 1/3 distributed at age 21, another 1/3 at age 25 and remainder at age 28.”
Any distributions on first spouse’s death. (These are usually small specific gifts of jewelry, pictures, books, etc. that
the surviving spouse does not need in continuing to run a household):
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
________________________________________
Division of estate among beneficiaries on death of last surviving spouse:

____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
________________________________________

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CLIENT INTAKE

Other or former names:

Do you have other residences in California? Yes No

Do you have children (including stepchildren or foster children)? Yes No

Please provide the following information regarding your former marriages:

Name of former spouse Living? Date of Death or Divorce agreement

D. Retirements and Life Insurance

B. Personal Representatives: Person(s) to handle your estate under your will

WIFE’S NOMINEE NAME __________________________________________________

HUSB NOMINEE NAME__________________________________________________

WIFE’S NOMINEE NAME__________________________________________________

HUSB NOMINEE NAME__________________________________________________

Division of estate among beneficiaries on death of last surviving spouse:

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