LEGACY WEALTH PLANNING 1Your Information2Children3Additional Information Your Information __________________________________________________________________________________________________First Name ** Last Name* Marital Status* Married Unmarried Email Address* Date of Birth * MM slash DD slash YYYY Client GenderSelect GenderMaleFemaleSpouse/Partner Information _________________________________________________________________________________________Spouse/Partner’s First Name Spouse/Partner’s Last Name Spouse’s Email Address Spouse/Partner’s Date of Birth MM slash DD slash YYYY Spouse GenderSelect GenderMaleFemalePhysical Address __________________________________________________________________________________________________Physical address line 1 Physical address line 2 Physical address city Physical State Physical StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Physical address zip/postal code Is your Mailing Address the same as Physical Address? My Mailing Address is the same My Mailing Address is different. I'd like to enter that address Mailing Address ________________________________________________________________________________________________________Mailing address line 1 Mailing address line 2 Mailing address city Mailing State Mailing StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Mailing address zip/postal code Phone Number 1 __________________________________________________________________________________________________Phone Number 1 DescriptionDescriptionHomeMobileOtherPhone 1 numberAdd A Second Number Add Another Phone Number Phone Number 2 ___________________________________________________________________________________________________Phone Number 2 DescriptionDescriptionHomeMobileOtherPhone 2 numberAdd A Third Number Add Another Phone Number Phone Number 3 __________________________________________________________________________________________________Phone Number 3 DescriptionDescriptionHomeMobileOtherPhone 3 number How many children do you have, living or deceased?01234More than 4If you have more than 4 children let us know during the personal consultation. Child 1 __________________________________________________________________________________________________________Child 1 First Name Child 1 Last Name Child 1 Date of Birth MM slash DD slash YYYY Child 1 GenderSelect GenderMaleFemaleChild 1 Email Child 1 PhoneChild 1's Parent(s)Child 1's Parent(s)BothProspectSpouseChild 1 Married? Yes No Child 1's ChildrenChild 1's Children01234More than 4Child 2 __________________________________________________________________________________________________________Child 2 First Name Child 2 Last Name Child 2 Date of Birth MM slash DD slash YYYY Child 2 GenderSelect GenderMaleFemaleChild 2 Email Child 2 PhoneChild 2's Parent(s)BothProspectSpouseChild 2 Married? Yes No Child 2's ChildrenChild 2's Children01234More than 4Child 3 __________________________________________________________________________________________________________Child 3 First Name Child 3 Last Name Child 3 Date of Birth MM slash DD slash YYYY Child 3 GenderSelect GenderMaleFemaleChild 3 Email Child 3 PhoneChild 3's Parent(s)BothProspectSpouseChild 3 Married? Yes No Child 3's ChildrenChild 3's Children01234More than 4Child 4 __________________________________________________________________________________________________________Child 4 First Name Child 4 Last Name Child 4 Date of Birth MM slash DD slash YYYY Child 4 GenderSelect GenderMaleFemaleChild 4 Email Child 4 PhoneChild 4's Parent(s)BothProspectSpouseChild 4 Married? Yes No Child 4's ChildrenChild 4's Children01234More than 4Additional Children InformationEnter Additional Children Information My estate has the following assets: Business/Partnerships Certificates of Deposit IRA/Retirement Plans Life Insurance Real Estate Stocks, Bonds, Mutual Funds Other 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: Enter Additional QuestionsApproximate gross value of my estate$0-50,000$50,001-100,000$100,001 - 150,000$150,001 - 200,000Over $200,000I have concerns about a Special Needs family member: Yes No 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.”)Please 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 affairsPlease enter a number from 1 to 10.Make sure Nursing Home costs don’t use up all my assetsPlease enter a number from 1 to 10.Make sure my wishes are honored regarding life support decisionsPlease enter a number from 1 to 10.I want to minimize all Death TaxesPlease enter a number from 1 to 10.After my death, make sure my estate stays with my children if they get divorcedPlease enter a number from 1 to 10.Protect my life insurance from Death TaxesPlease enter a number from 1 to 10.Protect my estate if my spouse gets remarried after my deathPlease enter a number from 1 to 10.After my death, protect my estate from my children’s creditorsPlease enter a number from 1 to 10.Protecting my special needs child after my deathPlease enter a number from 1 to 10.Funeral planning for my final arrangements and to make it easier for my familyPlease enter a number from 1 to 10.
