KWB Wealth Intake Form 1Wealth Manager Contact Info2Client Information3Decision-Makers4Beneficiaries5End-of-Life Decisions6Burial Wishes7Schedule Of Assets1/7Wealth Manager Contact InfoWealth Manager Information Wealth Manager'sFirst Name Wealth Manager'sLast Name Wealth Manager'sE-Mail Wealth Manager'sPhone Next0%Client Information [Strictly Confidential] Legal Name Spouse's Name Other Names Used Address County E-Mail Home Phone Cell Phone Age Marital Status Never marriedDivorcedWidowedMarried US Citizen? YesNo If no, indicate nationality Children YesNo Child 1 AGE or DOB Child 2 AGE or DOB Child 3 AGE or DOB Number of grandchildren Range of Ages Any deceased children? YesNo If yes, name(s) If yes, survived by issue? YesNo If yes, name(s) Do any of your beneficiaries have a learning disability, special educational, medical or physical needs? YesNo Do you have any relatives (other than children) who depend on you for all or part of their support? YesNo Do you think any of your beneficiaries have problems with spouses, drugs, alcohol or handling money? YesNo Do you wish to disinherit any of your children, grandchildren or any other close relative? YesNo If a named beneficiary dies before you, do you want the assets to go to that beneficiary's issue? YesNo Do you want assets passing to your beneficiaries to be held in trust until a specific age or ages? YesNo If Yes, what age? Do you expect to inherit substantial assets ($100,000 +)? YesNo Do you have an existing Will? YesNo Have you ever executed a trust (either revocable or irrevocable)? YesNo Have you ever filed a Federal Gift Tax Return? YesNo Do you have an existing General Power of Attorney? YesNo Do you currently hold any assets in Joint Tenancy with another person? YesNoBackNext16%Decision-MakersThe name of the person(s) that you want to be the decision maker concerning your estate upon your death: Trustee/Executor The name of the person(s) that you want to raise a child that is under 18 (if applicable): Guardian Advanced Health Care DirectiveThe name of the person(s) that you want to make any major medical decisions on your behalf: Client's Agent(s) Spouse's Agent(s) Power of Attorney for FiancesThe name of the person(s) that you want to make any major financial decisions on your behalf: Client's Agent(s) Spouse's Agent(s) BackNext33%BeneficiariesIndicate if you want to make any charitable gifts prior to funds being split among beneficiaries: Charity $ Or % Address Indicate how you want your estate distributed among your beneficiaries: Name Relationship Name Relationship Name Relationship Name Relationship Name Relationship Name Relationship Name Relationship State any specific concerns (not already mentioned) that you have regarding the distribution of your estate: BackNext50%End-of-Life Decisions Check the statement which best states your desires: (a) Choice NOT to Prolong Life(b) Choice to Prolong Life(a) I do not want my life to be prolonged if (1) I have an incurable and irreversible condition that will result in my death within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits.(b) I want my life to be prolonged as long as possible within the limits of generally accepted health care standards. Should your health care agent have the authority to make a disposition of a part or parts of your body (i.e., make any anatomical gifts)? YesNo Should your agent have the authority to authorize an autopsy even if an autopsy is not required by law? YesNo Do you wish to designate a primary physician? YesNo If yes, then enter contact info BackNext66%Burial Wishes At my death, I wish to be CrematedBuriedIf cremation, I would like my ashes disposed as follows: If cremation, I would like my ashes disposed as follows: I have already made arrangements at: BackNext83%Schedule of AssetsIndicate if you want to make any charitable gifts prior to funds being split among beneficiaries:Type of AssetLAST 4# OF ACCOUNT(S) Real Estate (address, city, state) (need copy of deed) Securities Life Insurance Policies (beneficiaries listed) Cash Type Assets (cash, annuities, notes due you) Business Interests (sole proprietorship, partnerships, closely held corporation, etc.) Retirement Plans (IRA, 401k, etc.) (beneficiaries listed) Vehicles (autos, R.V., boat) (year, make/ model) Personal Property (jewelry, furniture, antiques) Back100%Δ