Date of Consultation(Required)

Status(Required)

Married

Single

Widow

First Name(Required)

Last Name(Required)

Date of Birth(Required)

Untitled(Required)

Veteran

U.S. Citizen

Untitled

1st Marriage *:(Required)

Yes

Spouse/Partner’s First Name

Spouse/Partner’s Last Name

Date of Birth

Untitled(Required)

Veteran

U.S. Citizen

1st Marriage *:(Required)

Yes

Physical address line 1

Physical address line 2

Physical address city(Required)

Physical address state/province(Required)

Physical address zip/postal code(Required)

Phone 1 number(Required)

Office Phone:

Phone 2 number

Email Address(Required)

Spouse’s Email Address

Children’s Full Names

Gender

Date of Birth

Parent(s)

Married (Y/N)

Number of Grand Children

I have concerns about a Special Needs family member *:(Required)

Yes

My estate has the following assets *:(Required)

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(Required)

Please check one of the following boxes *:(Required)

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 *(Required)