Park Legal and Mediation
61 Java Street, Brooklyn, NY 11222 • (718) 490-1011
Professional Fiduciary Services Intake Form — Please complete at your own pace. Everything is kept strictly confidential.
Your Information
First Name
Middle Name
Last Name
Email Address
Phone Number
Primary Residence Address
Professional Advisory Team
Please provide contact information for your key financial and legal advisors.
CPA / Tax Preparer
Name
Firm
Phone
Email
Financial Advisor / Broker
Name
Firm
Phone
Email
Insurance Agent (Life/Property/Casualty)
Name
Firm
Phone
Email
Asset Inventory & Income Streams
For your privacy, please only provide the institution name and the last 4 digits of the account number. Do not provide full account numbers.
Bank Accounts
Institution Name
Account Type
Last 4 Digits
Branch Location
+ Add Bank Account
Investment/Retirement Accounts
Brokerage Name
Account Type (IRA, 401k, etc.)
Last 4 Digits
+ Add Investment Account
Real Estate Owned
Property Address
Property Type (Primary, Vacation, Land)
Ownership %
+ Add Real Estate
Major Income Sources
Income Source (Social Security, Pension, etc.)
Estimated Amount
Frequency
Estimated Date of Receipt
+ Add Income Source
Rental Income
Property Address
Tenant/Manager Contact
Rent Amount
When is rent due?
+ Add Rental Property
Business Ownership & Intellectual Property
Business/IP Name
Entity Type / IP Type
Ownership %
Maintenance Fees/Deadlines
+ Add Business/IP
Additional Notes / Explanations
Use this space to explain anything that doesn't fit neatly into the tables above.
Liabilities, Debts & Recurring Expenses
Mortgages / Home Equity Lines
Lender Name
Property Secured
Approx. Balance
Payment Frequency & Due Date
+ Add Mortgage/HELOC
Recurring Expenses (Monthly/Quarterly/Annual)
Expense Type (Utilities, Insurance, etc.)
Estimated Amount
Frequency
Estimated Due Date
+ Add Recurring Expense
Auto-Pay Bills
Expense Name
Paid From Which Account?
+ Add Auto-Pay Bill
Credit Cards
Issuer Name
Last 4 Digits
Typical Due Date
+ Add Credit Card
Charitable Commitments
Organization Name
Pledge/Donation Amount
Frequency
Due Date
+ Add Charitable Commitment
Additional Notes / Explanations
Use this space to explain anything that doesn't fit neatly into the tables above.
Digital Assets & Logistics
Password Manager
Do you use one? (e.g., 1Password, LastPass). Where is the master password stored?
Device Access & Cloud Storage
Passcodes for primary smartphone/computer. Apple iCloud, Google Drive, Dropbox accounts.
Important Documents Location
Where are the original Will, birth certificate, Social Security card, and passport kept?
Keys & Access
Location of spare house keys, vehicle keys, mail keys, alarm codes, or gate codes.
Health & Personal Care
Primary Care Physician
Name
Clinic
Phone
Key Specialists
Names, specialties, phone numbers.
Preferred Hospital
Hospital name and location.
Health Information & Records
Where are medical records kept? Current medications, allergies, existing diagnoses.
End-of-Life & Living Will Alignment
Do you currently have a Living Will?
Yes
No
Please email a copy of your existing Living Will to our office.
Are there any revisions or updates you would like to discuss?
End-of-Life Preferences
Specific preferences regarding life support, religious beliefs, organ donation.
Personal Care & Lifestyle Preferences
Preferences for assisted living vs. in-home care. Dietary restrictions.
Pet Care Instructions
Names of pets, preferred caretakers, dietary needs, veterinarian contact info.
Review & Submit
Please review your entries. When you are ready, click Submit to securely send your information to Park Legal and Mediation.
Please fill out all required fields before submitting.
Thank you! Your information has been securely submitted.
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