LEGACY WEALTH PLANNING CONSULTATION FORM Date of Consultation* MM slash DD slash YYYY Status* Married Single Widow First Name* Last Name* Date of Birth* MM slash DD slash YYYY Untitled* Veteran U.S. Citizen Untitled 1st Marriage:* Yes No Spouse/Partner’s First Name Spouse/Partner’s Last Name Date of Birth MM slash DD slash YYYY Untitled* Veteran U.S. Citizen 1st Marriage:* Yes No Physical address line 1 Physical address line 2 Physical address city* State*State *AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificPhysical address zip/postal code* Phone 1 number*Office Phone:Phone 2 numberEmail Address* Spouse’s Email Address Children’s Full NamesGenderDate of BirthParent(s)Married (Y/N)Number of Grand Children I have concerns about a Special Needs family member:* Yes No My estate has the following assets:* Real Estate IRA/Retirement Plans Business/Partnerships Stocks, Bonds, Mutual Funds Life Insurance Certificates of Deposit Bank Account Approximate 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 Me 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 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 Contact I 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
