LEGACY WEALTH PLANNING 1 Your Information2 Children3 Additional Information Your Information __________________________________________________________________________________________________First Name*Last Name*Marital Status*MarriedUnmarriedEmail Address* Date of Birth* Date Format: MM slash DD slash YYYY Client GenderSelect GenderMaleFemaleSpouse/Partner Information _________________________________________________________________________________________Spouse/Partner’s First NameSpouse/Partner’s Last NameSpouse’s Email Address Spouse/Partner’s Date of Birth Date Format: MM slash DD slash YYYY Spouse GenderSelect GenderMaleFemalePhysical Address __________________________________________________________________________________________________Physical address line 1Physical address line 2Physical address cityPhysical State Physical StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Physical address zip/postal codeIs your Mailing Address the same as Physical Address?My Mailing Address is the sameMy Mailing Address is different. I'd like to enter that addressMailing Address ________________________________________________________________________________________________________Mailing address line 1Mailing address line 2Mailing address cityMailing State Mailing StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Mailing address zip/postal codePhone 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 NameChild 1 Last NameChild 1 Date of Birth Date Format: 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?YesNoChild 1's ChildrenChild 1's Children01234More than 4Child 2 __________________________________________________________________________________________________________Child 2 First NameChild 2 Last NameChild 2 Date of Birth Date Format: MM slash DD slash YYYY Child 2 GenderSelect GenderMaleFemaleChild 2 Email Child 2 PhoneChild 2's Parent(s)BothProspectSpouseChild 2 Married?YesNoChild 2's ChildrenChild 2's Children01234More than 4Child 3 __________________________________________________________________________________________________________Child 3 First NameChild 3 Last NameChild 3 Date of Birth Date Format: MM slash DD slash YYYY Child 3 GenderSelect GenderMaleFemaleChild 3 Email Child 3 PhoneChild 3's Parent(s)BothProspectSpouseChild 3 Married?YesNoChild 3's ChildrenChild 3's Children01234More than 4Child 4 __________________________________________________________________________________________________________Child 4 First NameChild 4 Last NameChild 4 Date of Birth Date Format: MM slash DD slash YYYY Child 4 GenderSelect GenderMaleFemaleChild 4 Email Child 4 PhoneChild 4's Parent(s)BothProspectSpouseChild 4 Married?YesNoChild 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:YesNoWhat 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.
