Samantha A Fix, Esq.
Law Office of Samantha Fix
1457 Knapp Street, Bronx, New York 10469
tel: 516-716-8701 I 516-716-8700
samantha@SamFixLaw.com I www.SamFixLaw.com

You are invited to complete a secure, online form that will provide Law Office of Samantha Fix with information about you, your family, and the people you trust to act for you. This information will serve as the basis of your estate plan. All information is confidential; any personal or financial information obtained from you will never be released without your prior permission or direction.

Contact information: Client

Prefix

First name *

Middle name

Last name *

Date of birth

Company

Emails

Email Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

What is your marital status?

Single

Married

Divorced

Widowed

Life Partner

Do you have any children?

Yes

Do you currently have a Will? Or any estate planning documents. (DO NOT UNSTAPLE)

Yes

Getting to Know You

Please complete three short surveys to help us understand what you hope to accomplish

with your estate plan. This will help us provide you with the best recommendations and design

a plan to meet your needs.

Are there any people you would like to name as beneficiaries that are not already listed?

Yes

What type of Property do you own?

Please select all that apply.

Real Property

Personal Property

Retirement Accounts

Stocks/Bonds

Pension

Life insurance

How important is getting your affairs in order and creating a comprehensive plan to manage your affairs in case of death or disability?

High Concern

Some Concern

Low Concern

No Concern

Disinheriting a family member?

High Concern

Some Concern

Low Concern

No Concern

Providing for Charities at the time of death

High Concern

Some Concern

Low Concern

No Concern

Planning for the transfer and survival of a family business.

High Concern

Some Concern

Low Concern

No Concern

Avoiding or reducing Estate taxes.

High Concern

Some Concern

Low Concern

No Concern

Avoiding probate.

High Concern

Some Concern

Low Concern

No Concern

Reducing administrative cost at the time of death

High Concern

Some Concern

Low Concern

No Concern

Avoiding will contest or other disputes upon death.

High Concern

Some Concern

Low Concern

No Concern

Protecting assets.

High Concern

Some Concern

Low Concern

No Concern

Protecting privacy from business competitors, predators, and dishonest and curious people in the event of disability or at time of death.

High Concern

Some Concern

Low Concern

No Concern

Are you receiving Social Security, disability, or other government benefits?

Yes

Are you making payments pursuant to a divorce or property settlement order?

Yes

Have you ever filed federal or state gift tax returns?

Yes

Have you already completed an estate plan, such as a will or trust?

Yes

Do you currently support any charitable organizations that you wish to provide for when you die?

Yes

Are you currently the beneficiary of a trust or estate?

Yes

Do you provide primary or other major financial support to adult children or other adults?

Yes

Would you like to make specific gifts of real estate, personal property, or cash to individuals or charities? Please add a description of the specific gifts you would like to make and indicate the individual or charity to receive each gift.

Yes

Agents

Who would you like to make decisions for you in case of incapacity, who will be the guardian of your minor children, who do you want to be your Trustee and successor Trustee for the Trust, and who do you want named your Executor and successor Executor? I single person can fulfill more than one role. For example, John Smith can be your Trustee, Executor, and a Guardian for your minor child.

Contact information: Client

What is your marital status?

Do you have any children?

Do you currently have a Will? Or any estate planning documents. (DO NOT UNSTAPLE)

Getting to Know You

Are there any people you would like to name as beneficiaries that are not already listed?

What type of Property do you own?

How important is getting your affairs in order and creating a comprehensive plan to manage your affairs in case of death or disability?

Disinheriting a family member?

Providing for Charities at the time of death

Planning for the transfer and survival of a family business.

Avoiding or reducing Estate taxes.

Avoiding probate.

Reducing administrative cost at the time of death

Avoiding will contest or other disputes upon death.

Protecting assets.

Protecting privacy from business competitors, predators, and dishonest and curious people in the event of disability or at time of death.

Are you receiving Social Security, disability, or other government benefits?

Are you making payments pursuant to a divorce or property settlement order?

Have you ever filed federal or state gift tax returns?

Have you already completed an estate plan, such as a will or trust?

Do you currently support any charitable organizations that you wish to provide for when you die?

Are you currently the beneficiary of a trust or estate?

Do you provide primary or other major financial support to adult children or other adults?

Would you like to make specific gifts of real estate, personal property, or cash to individuals or charities? Please add a description of the specific gifts you would like to make and indicate the individual or charity to receive each gift.

Your Property

Agents

Executor Name

Executors Address

Executors Phone Number

Executors E-mail

Successor Executor Name

Successor Executors Address

Successor Executor Phone

Successor Executor Email

Trustee Name

Trustee Address

Trustee Phone Number

Trustee Email

Successor Trustee Name

Guardian of Minor Child

Guardian of Minor Child

Health Care Proxy

Power of Attorney