Legacy Wealth Planning Consultation FormDate of Consultation* Date Format: MM slash DD slash YYYY Status*MarriedSingleFirst Name*Last Name*Date of Birth* Date Format: MM slash DD slash YYYY Untitled* Veteran U.S. Citizen1st Marriage:*YesNoSpouse/Partner’s First NameSpouse/Partner’s Last NameDate of Birth Date Format: MM slash DD slash YYYY Untitled* Veteran U.S. Citizen1st Marriage:*YesNoPhysical address line 1Physical address line 2Physical address city*Physical address state/province* State *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Physical address zip/postal code*Phone 1 number*Office Phone:Phone 2 numberEmail Address* Spouse’s Email Address Children’s Full NamesSexDate of BirthParentMarried (Y/N)Number of Grand Children I have concerns about a Special Needs family member:*YesNoMy estate has the following assets:* Real Estate IRA/Retirement Plans Business/Partnerships Stocks, Bonds, Mutual Funds Life Insurance Certificates of DepositApproximate gross value of my entire estate*Please check one of the following boxes:*I am ready to proceed with the creation of my plan.My loved one is already in a nursing home, I am ready to proceed with a plan.I am not interested in creating a plan at this time. I’m here for general information only.I need the following questions answered before I am ready to proceed with the creation of my plan:List What Really Matters to MePlease rate the following estate planning goals and concerns on a scale of 1 to 10. (1 being “not important at all” and 10 being “very important.”)Make sure there’s a written plan to handle my affairs*Please enter a number from 1 to 10.I want to avoid Living Probate and/or Death Probate*Please enter a number from 1 to 10.Make sure Nursing Home costs don’t use up all my assets*Please enter a number from 1 to 10.Make sure my wishes are honored regarding life support decisions*Please enter a number from 1 to 10.I want to minimize all Death Taxes*Please enter a number from 1 to 10.After my death, make sure my estate stays with my children if they get divorced*Please enter a number from 1 to 10.Protect my life insurance from Death Taxes*Please enter a number from 1 to 10.Protect my estate if my spouse gets remarried after my death*Please enter a number from 1 to 10.After my death, protect my estate from my children’s creditors*Please enter a number from 1 to 10.Protecting my special needs child after my death*Please enter a number from 1 to 10.Funeral planning for my final arrangements and to make it easier for my family*Please enter a number from 1 to 10.Permission to ContactI authorize the law firm to occasionally mail, fax or email information to me. I understand that I can unsubscribe to communication from the firm at any time and I also understand that the law firm will not share or sell my contact information to anyone. I prefer to be contacted at the email address listed above.Signature*Signature*
