Date of Consultation(Required)

Status(Required)

Married

Single

Date of Birth(Required)

Client 1's First Name(Required)

Client 1's Middle Name

Client 1's Last Name(Required)

Untitled(Required)

Veteran

U.S. Citizen

1st Marriage:(Required)

Yes

Client 2’s First Name

Client 2's Middle Name

Client 2's Last Name

Date of Birth

Untitled(Required)

Veteran

U.S. Citizen

1st Marriage:(Required)

Yes

Street address line 1(Required)

Street address line 2

Physical address city(Required)

Physical address state/province(Required)

Physical address zip/postal code(Required)

Phone 1 number(Required)

Cell Phone:

Spouse's Cell Phone

Email Address(Required)

Spouse’s Email Address

Children's data

Child's Full Name

Gender

Date of Birth

Parent(s)

Married (Y/N)

Number of Grand Children

Children's data

Child's Full Name

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)

IRA/Retirement Plans

Business/Partnerships

Stocks, Bonds, Mutual Funds

Life Insurance

Certificates of Deposit

In state real estate

Out of state real estate

Approximate gross value of my entire estate

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)