Estate Planning
GUARDIANSHIP INTERVIEW FORM
Please fill out completely and fax or mail back. This form is extremely
important. Your accuracy and completeness in responding will help us best
represent you. Please read our website article to help you understand how
guardianships are handled
ALL THE PAGES
AND SECTIONS OF THIS FORM MUST BE COMPLETED PRIOR TO SEEING THE ATTORNEY.
WRITE YOUR SPECIFIC QUESTIONS AT THE END OF THE LAST PAGE. PLEASE HELP
YOURSELF TO THE FREE INFORMATION BROCHURES IN THE RECEPTION AREA.
PLEASE PRINT CLEARLY
Your Full Name: [Person Filling out Form]
______________________________________________________
First
Last
Street Address:
________________________________________
City ____________________ State ____ Zip Code
_____________
Telephone Numbers: Cell:
__________________________________
Day: ____________________ Night:
________________________
E-mail address:
__________________________________________
Referred By:
___________________________________________
If referred by a person,
is this a client or attorney? If you heard about this law office by the
internet, which search engine? What search terms did you use?
Today's Date ___________________________________________
1. Name of person for whom you seek Guardianship:
________________
Guardianship Questionnaire rev
8/16/12
2. Current address and phone for
incapacitated person whom Guardianship is sought:
____________________________________________________________
____________________________________________________________
3. Your relationship
to person: _________________________________
4. Incapacitated person is of the age of
________________., DOB _______
5. The other kin of Incapacitated
person are:
___________________, relationship _______________,
residing at: ___________________,
___________________, relationship _______________,
residing at: _________________,
___________________, relationship ______________,
residing at: ____________________
6. Name, address and fax number of Doctor 1 who
will sign Affidavit that person is incapacitated:
____________________________________________________________
____________________________________________________________
7. Name, address and fax number of Doctor 2 who
will sign Affidavit that person is incapacitated:
____________________________________________________________
____________________________________________________________
8. Is there a Will? _____
Did you bring a
photocopy? ____
B. Is there a Power of Attorney? _____ Did you bring a
copy? ____
C. Do You Have a Copy of the Deed? ________
ASSETS
The court rules require details of assets be set forth in a Guardianship case.
SCHEDULE “A” REAL PROPERTY If none, write
none
1. Street and Number
_____________________________________
Town: ____________________
Lot: ___ Block: ____ County:
____________________
Title/Owner of Record: _______________
Tax Assessor Assessed Value: $____________________
Full Market Value of Property:
$____________________
Mortgage Balance: $______________________
Any other Real Estate: $______________________
SCHEDULE “B (1)” BANK ACCOUNTS, STOCK,
CD, OTHER ASSETS
All Other Personal Property Owned Individually or Jointly; Market Value,
Indicate the Manner of Registration at Date of Death.
If
none, write none for each line
Bank Accounts/ Brokerage Accounts - Name of Bank,
Acct. # ___________________________________________ $_________
__________________________________________
$_________
___________________________________________
$_________
__________________________________________
$_________
Stock - Name of Stock Co., Acct. #
________________ $_________
___________________________________________
$_________
Investment Bonds., Acct.
#
$_________
___________________________________________
$_________
Cars
_______________________________________ $_________
Other assets over $10,000
______________________ $_________
___________________________________________
$_________
___________________________________________
$_________
___________________________________________
$_________
Liabilities More Than $2,000: If none, write none
____________________________________________________________
____________________________________________________________
Estimated Gross Estate:
$__________________________________
Set forth several specific acts of incompetency by
the alleged incapacitated person:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
PLEASE USE THIS PAGE
TO WRITE YOUR SPECIFIC QUESTIONS FOR THE ATTORNEY:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
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