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Estate Planning Intake FormLarry Bark2025-02-11T21:01:03+00:00

EP Questionnaire

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Step 1 of 5

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Estate Planning New Client Questionnaire with Healthcare and Powers of Attorney for Asset Management

Carefully read all instructions to help us properly prepare your documents.

The PURPOSE OF THIS QUESTIONNAIRE is to assist us in accurately preparing your trust documents including healthcare and asset powers of attorney.

The PURPOSE OF THIS QUESTIONNAIRE is to allow us to quickly understand the estate planning which you request our assistance. To better help you, we request you complete this Questionnaire as best as possible. If a question is not applicable, please leave it BLANK. If you have any questions, write them on a separate sheet of paper and we will be happy to answer them when we meet.

The purpose of these documents is to reduce or eliminate legal fees you will pay to attorneys you do not know and to reduce or eliminate Nevada Guardianship Court involvement in your life. Nevada law says your personal assets are responsible to pay the following costs and fees if a guardianship is ordered:

  1. Court costs (Estimate up to $1,000 first year),
  2. Fees paid to your guardian,
  3. Legal fees paid to your guardian's attorney (currently $350 - $500/hour),and
  4. Legal fess paid to a court appointed attorney to protect your interest

All these costs and fees easily add up to tens of thousands of dollars in the first year and several thousands of dollars for all following years. This will likely devastate your savings and retirement to pay legal fees to attorneys to pay his/her children’s private school tuition, and thus not paid for your benefit or family.

The ESTIMATED TIME to complete this questionnaire is 15 minutes.

For married individuals: Steps 1 and 2 should be completed jointly. Steps 3, 4, and 5 are to be completed individually by the first spouse. The second spouse will complete their portion using the Healthcare and Power of Attorney link provided via email. If you need the link to be resent, please don’t hesitate to contact our office.

Below you will be given the opportunity to select up to three (3) people to serve as your healthcare agent and three (3) people to serve as your financial agents. An “Agent” is/are the person(s) you want to decide matters for you when you cannot while you are living. Do not feel obligated to choose all three (3) for each type of agent. Some people simply do not have enough people to choose from to fill all slots. If you only have one person to serve as your healthcare and financial agent, then so be it. Please DO NOT COMPLETE the questionnaire if you do not have any one to serve as your healthcare or financial agent; call our office to advise us. When you come in we will discuss alternatives.

Documents we will draft for you are:

  1. Directive to Physician (aka Living Will)
  2. Durable Power of Attorney for Healthcare
  3. HIPAA Authorization
  4. Agreement with Nevada Secretary of State Lock Box
  5. Nomination of Guardian for your Person and Estate
  6. Statutory Form Power of Attorney for Asset Management

What You need to have before you start this questionnaire.

You will need the following information for input and responding to questions below:

  1. Your Driver’s License.
  2. Your current Address, City, State, Zip Code, Telephone Number, Birth Date, and Email Address. If different from your driver’s license, provide updated information.
  3. Your First, Second and Third Healthcare Agents - Names, Addresses, Telephone Numbers, Email Addresses and relationship to you.
  4. Your First, Second and third Financial Agents - Names, Addresses, Telephone Numbers, Email Addresses and relationship to you.
Conditions of Our Services*
Our fixed fee on this matter relies upon the information you input below. Any changes other than minor correction of a name misspelling, minor address change, number or email correction will be billed at our current hourly rates. That means changes in persons, including order, you want to serve as your agent or request additional information, or other changes deviating from your input. Current rates for legal secretaries and support staff are $125.00 per hour. Current rate for attorney review of changes ranges from $350.00 to $450.00 per hour. Minimum charge to facilitate changes other than minor corrections described above is $150.00.
Acknowledgement*
Your checking this box and completing the questions below evidences your agreement to the fixed fee and all conditions to our services.
Who referred you to us?

The Following Questions are about you.

Below type your full, middle, last and address as shown on your drivers license below.
Your Name
Name
Your Address
Your Email
Your Date of Birth
**The Nevada Secretary of State requests this information to catalogue your healthcare documents filed in the Living Will Lockbox.
When will you be retiring?

If you have a divorce agreement from your previous marriage please bring it with you

Your Spouse's/Partner's Information

Your Spouses's/Partner's Name
Your Spouses's/Partner's Name
Their date of birth
When will they be retiring?

Children & Family Information

First Child

First Child's Name
DOB
Address

Second Child

Second Child's Name
DOB
Address

Third Child

Third Child's Name
DOB
Address

Fourth Child

Fourth Child's Name
DOB
Address

Fifth Child

Fifth Child's Name
DOB
Address

Name
Address
Name
Address
What are your goals in creating or upgrading your estate plan? (check all that apply)

Marriage Information

Date of Marriage

Banks, Savings, & Loans & Credit Unions

Account balance will vary, so please list approximate balance of each account.
Type
Type
Type
Type
Type

Mutual Funds and/or Brokerage Accounts

Type
Type
Type
Type
Type

Promissory Notes & Deeds of Trust Owed to You

Real Estate

1. Main Property Address
1. Second Property Address

IRA Accounts & Company Retirement Plans

Type
Type
Type
Type
Type

Life Insurance

Business Information

Other Miscellaneous Assets

Selecting Healthcare Agent(s) to decide health care matters for you when you cannot

A Healthcare Agent is someone who you select to decide personal healthcare matters for you when you cannot because of age, illness or injury. The individual you select to be your healthcare agent will also be nominated to be your guardian for your person (someone who will decide healthcare matters for you such what doctors you see, assist with medication, where you will live, etc.).

First Healthcare Agent's Name
First Healthcare Agent's Address
**If you choose this option, you won’t need to enter information for your First Financial Agent. The details provided above will automatically apply to your First Financial Agent if you select “Yes.”
Second Healthcare Agent's Name
Second Healthcare Agent's Address
**If you choose this option, you won’t need to enter information for your Second Financial Agent. The details provided above will automatically apply to your Second Financial Agent if you select “Yes.”
Third Healthcare Agent's Name
Third Healthcare Agent's Address
**If you choose this option, you won’t need to enter information for your Third Financial Agent. The details provided above will automatically apply to your Third Financial Agent if you select “Yes.”

A Financial Agent is someone who you select to decide financial matters for you when you cannot because of age, illness or injury. The individual you select to be your financial agent will also be nominated to be your guardian for your estate. "Estate" is the term used in the Nevada Revised Statutes that essentially means all property you own that is not titled in a trust of any kind. In other words, all property titled in your name, including property you hold joint title with another person such as your spouse is "estate" property.

Financial Agent's Information

First Financial Agent's Name
First Financial Agent's Address
Second Financial Agent's Name
Second Financial Agent's Address
Third Financial Agent's Name
Third Financial Agent's Address

HIPPA Release Information

This section describes a HIPAA release form.The Health Insurance Portability and Accountability Act (federal law aka HIPAA) provides you may allow named persons to inquire with your healthcare providers on your health status, prognosis, and other related matters. The privilege of an individual you name to inquire about your healthcare DOES NOT PROVIDE authority to decide healthcare matters and provide direction to healthcare providers. The authority to provide direction to healthcare providers are left to your agent named in a Healthcare Power of Attorney (a completely different document).Under the Unites States Constitution, states are to recognize other states documents, judgements, etc. so long as such document, judgement do not violate another state's public policy. Each state in the Union has created their own healthcare power of attorney (Healthcare POA). Frequently, but not always, states have passed their own HIPAA equivalent language and waivers of release of information. One state's waiver language may not meet public policy for another state.As such, since most persons travel among the states, and a real possibility of a state (not Nevada) may not recognize the Nevada healthcare waiver language, we draft for you a HIPAA release language that fall directly out of the United States Code. Under the Constitution, US statutes and laws supersede state statutes and laws when they conflict. Thus the HIPAA waiver will be sufficient to cover a state other than Nevada. The HIPAA waiver is an important form to follow you though out all 50 states to ensure your designated Healthcare POA can decide matters for you incases of when you are in need of medical assistance.This is in addition to your Healthcare Agents which will be the first listed. Please select Yes to add any additional person(s) and No to move on to the next section.
Type the full name of the first person you want to be on your HIPPA Release form
Do not add any of the Healthcare Agents that you have already provided. They will be on the HIPPA Release form automatically.
Type the full name of the second person you want to be on your HIPPA Release form
Do not add any of the Healthcare Agents that you have already provided. They will be on the HIPPA Release form automatically.
Type the full name of the third person you want to be on your HIPPA Release form
Do not add any of the Healthcare Agents that you have already provided. They will be on the HIPPA Release form automatically.
Type the full name of the fourth person you want to be on your HIPPA Release form
Do not add any of the Healthcare Agents that you have already provided. They will be on the HIPPA Release form automatically.
Type the full name of the fifth person you want to be on your HIPPA Release form
Do not add any of the Healthcare Agents that you have already provided. They will be on the HIPPA Release form automatically.
This helps us make sure every step is as easy as possible for our clients. Thank you!
Consent

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Contact Info

Kirk D. Kaplan Esq., CPA
(702) 202 4153
Send an Email
6980 O’Bannon Dr #100,
Las Vegas, NV 89117

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