JODI HEAD LOPEZ & ASSOCIATES P.C.

Jodi Head Lopez

Shawn E. Vandenberg
Tanya R. Swenson

CLIENT INTERVIEW SHEET

Date: _________________________

Please complete this questionnaire. If you will spend the time to complete all
items, you will give us the background information necessary to begin to understand the
complexity of the personal aspects of your probate issue. All information will be held in
strict confidence.

PART I - PERSONAL DATA

NAME of DECEDENT:_________________________________________________________

Alias Names (if any):____________________________________________________________

Street Address:_________________________________________________________________

City:___________________________ State:____________________ Zip Code:_____________

Date of Birth:__________________________________________________________________

Place of Birth:__________________________________________________________________

Date of Death:__________________________________________________________________

Place of Death:_________________________________________________________________

Social Security Number:__________________________________________________________

Was Decedent a U.S. citizen? Yes: _ No:___

If naturalized U.S. citizen, Date and Place of Naturalization:_____________________________

______________________________________________________________________________

Location of Will, if any:__________________________________________________________

Date of Will:___________________________________________________________________

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Location of Codicils, if any:_______________________________________________________

Date of Codicils:________________________________________________________________

NAME of PERSONAL REPRESENTATIVE:______________________________________

Street Address:_________________________________________________________________

City:___________________________ State:____________________ Zip Code:_____________

Home #:_______________________________Cell #:__________________________________

Work #:________________________________Fax #:__________________________________

E-mail:_________________________________Pgr #:__________________________________

Relationship to Decedent:_________________________________________________________

NAME of ALTERNATE REPRESENTATIVE:_____________________________________

Street Address:_________________________________________________________________

City:___________________________ State:____________________ Zip Code:_____________

Home #:_______________________________Cell #:__________________________________

Work #:________________________________Fax #:__________________________________

E-mail:_________________________________Pgr #:__________________________________

Relationship to Decedent:_________________________________________________________

PART II - BENEFICIARIES or HEIRS AT LAW

NAME of SPOUSE/DOMESTIC PARTNER:_______________________________________

Street Address:_________________________________________________________________

City:___________________________ State:____________________ Zip Code:_____________

Home #:_______________________________Cell #:__________________________________

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Work #:________________________________Fax #:__________________________________

E-mail:_________________________________Pgr #:__________________________________

Date of Birth:__________________________________________________________________

Social Security Number:__________________________________________________________

Date and place of marriage/domestic partnership:______________________________________

Status of Spouse: Living Deceased Under Conservatorship____________

CHILDREN'S INFORMATION:

Name Living Age Birthdate Married Address

__________________ Yes/No ____ __________ Yes/No ________________

__________________ Yes/No ____ __________ Yes/No ________________

__________________ Yes/No ____ __________ Yes/No ________________

__________________ Yes/No ____ __________ Yes/No ________________

__________________ Yes/No ____ __________ Yes/No ________________

__________________ Yes/No ____ __________ Yes/No ________________

For each child, state the name of the child's other parent, if not decedent's surviving
spouse/partner.

OTHER DEPENDENTS, IF ANY:

Name:_______________________ Age ________ Residence:___________________

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GRANDCHILDREN'S INFORMATION
Name: Age: Birthdate: Names of parents:
___________________________ ____ ____________ ________________________
________________________

Name: Age: Birthdate: Names of parents:

___________________________ ____ ____________ ________________________
________________________

Name: Age: Birthdate: Names of parents:

___________________________ ____ ____________ ________________________
________________________

Please list the names of decedent's parents, brothers, and sisters, and state whether they are
living, and if so, list their city and state of residence.

Name: Relationship: Living Residence:

_____________________ ________________ Yes/No ________________________

_____________________ ________________ Yes/No ________________________

_____________________ ________________ Yes/No ________________________

_____________________ ________________ Yes/No ________________________

List, as well, the same information for the surviving spouse's/partner's parents and siblings.

Name: Relationship: Living Residence:

_____________________ ________________ Yes/No ________________________

_____________________ ________________ Yes/No ________________________

_____________________ ________________ Yes/No ________________________

_____________________ ________________ Yes/No ________________________

Please provide the following information regarding decedent's former marriages, if any:

Name of former spouse Living Date of Death or Divorce

________________________ YES/NO ______________________

________________________ YES/NO ______________________
________________________ YES/NO ______________________

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 PART III - DECEDENT'S DESIGNEES

TRUSTEE (i.e., the person who will be responsible for the long-term management of property
for the surviving spouse, children or other beneficiaries)

Name of Trustee:________________________________________________________________

Address:______________________________________________________________________

Home Phone No.:__________________ Wk Phone No.:________________________________

1st Alternate Trustee:____________________________________________________________

2nd Alternate Trustee: ___________________________________________________________

3rd Alternate Trustee:____________________________________________________________

GUARDIAN OF MINOR CHILDREN (i.e. the person who will take physical care of any
minor children should both parents die)

Name of Guardian_______________________________________________________________

Address:______________________________________________________________________

Home Phone No.:__________________ Wk Phone No.:________________________________

1st Alternate Guardian:___________________________________________________________

2nd Alternate Guardian:__________________________________________________________

3rd Alternate Guardian:__________________________________________________________

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 PART IV - ASSETS

Describe decedent's property. If known, indicate whether the property is separate property, the
surviving spouse's/partner's separate property, or community property. If not, state the name(s)
which appear on the title, if known, and state whether the property is held with right of
survivorship, if known.

CASH & ACCOUNTS WITH FINANCIAL INSTITUTIONS: (include cash, traveler's

checks, money orders, and accounts with commercial banks, savings banks, credit unions, etc.)

CASH

Cash on hand:__________________________________________________________________

Traveler's checks:_______________________________________________________________

Money orders:__________________________________________________________________

ACCOUNTS

Name of financial institution:_____________________________________________________

Account title:___________________________________________________________________
Account number:________________________________________________________________
Type of account: (checking/savings/money market/CD/Other)____________________________
Current account balance (as of ): $___________________________________________

Name of financial institution:_____________________________________________________

Account title:___________________________________________________________________
Account number:________________________________________________________________
Type of account: (checking/savings/money market/CD/Other)____________________________
Current account balance (as of ): $___________________________________________

Name of financial institution:_____________________________________________________

Account title:___________________________________________________________________
Account number:________________________________________________________________
Type of account: (checking/savings/money market/CD/Other)____________________________
Current account balance (as of ): $___________________________________________

Name of financial institution:_____________________________________________________

Account title:___________________________________________________________________
Account number:________________________________________________________________
Type of account: (checking/savings/money market/CD/Other)____________________________
Current account balance (as of ): $___________________________________________

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 Last Will and Testament:

1. Do you have a will?_________________________________________________

a. If so, prepared by whom?_______________________________________

2. Does your spouse have a will?________________________________________

a. If so, prepared by whom?_______________________________________

Mail

At what address do you wish to receive mail from this office?

________________________________________________________________
________________________________________________________________

Referral:

Who/What referred you to this office?___________________________________

I understand that there will be an initial $ 125.00, consultation fee regardless of whether
I decide to take any legal action or not.

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