Estate Planning Consultation Form 1Your Information2Children3Additional Information Your InformationIMPORTANT: Please use legal name (how it appears on your license or passport) including, middle initial, and suffix if applicable.First Name *(Required) Middle Name Last Name(Required) Marital Status(Required) Married Unmarried Email Address(Required) Date of Birth *(Required) MM slash DD slash YYYY Client Gender(Required) IMPORTANT: Please use legal name (how it appears on your license or passport) including, middle initial, and suffix if applicable.Spouse/Partner’s First Name Spouse/Partner’s Middle Name Spouse/Partner’s Last Name Spouse’s Email Address Spouse/Partner’s Date of Birth * MM slash DD slash YYYY Spouse/Partner InformationClient Gender(Required) Children Of Spouse 1(Required) Children Of Spouse 2(Required) Children Of Both(Required) Physical AddressPhysical address line 1 *(Required) Physical address line 2 Physical address city(Required) Physical State(Required)Physical 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(Required) Is your Mailing Address the same as Physical Address?(Required) My Mailing Address is the same My Mailing Address is different. I’d like to enter that address Mailing AddressMailing address line 1(Required) Mailing address line 2 Mailing address city *(Required) Mailing State *(Required) 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(Required) Phone Number 1Phone Number 1 Description(Required)DescriptionHomeMobileOtherPhone 1 number(Required)Add A Second Number Add Another Phone Number Phone Number 2Phone Number 2 Description(Required)DescriptionHomeMobileOtherPhone 2 number(Required)Add A Third Number Add Another Phone Number Phone Number 3Phone Number 3 Description(Required)DescriptionHomeMobileOtherPhone 3 number(Required) How many children do you have, living or deceased?(Required)01234More than 4If you have more than 4 children let us know during the personal consultation. Child 1IMPORTANT: Please use legal name (how it appears on your license or passport) including, middle initial, and suffix if applicable.Child 1 First Name Child 1 Middle Name Child 1 Last Name Child 1 Date of Birth(Required) MM slash DD slash YYYY Client Gender Child 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 Children *01234More than 4Child 2IMPORTANT: Please use legal name (how it appears on your license or passport) including, middle initial, and suffix if applicable.Child 2 First Name Child 2 Middle Name Child 2 Last Name Child 2 Date of Birth MM slash DD slash YYYY Client Gender Child 2 Email Child 2 PhoneChild 2's Parent(s)Child 2's Parent(s) *BothProspectSpouseChild 2 Married? Yes No Child 2's ChildrenChild 2's Children *01234More than 4Child 3IMPORTANT: Please use legal name (how it appears on your license or passport) including, middle initial, and suffix if applicable.Child 3 First Name Child 3 Middle Name Child 3 Last Name Child 3 Date of Birth MM slash DD slash YYYY Client Gender Child 3 Email Child 3 PhoneChild 3's Parent(s)Child 3's Parent(s) *BothProspectSpouseChild 3 Married? Yes No Child 3's Children(Required)Child 3's Children *01234More than 4Child 4IMPORTANT: Please use legal name (how it appears on your license or passport) including, middle initial, and suffix if applicable.Child 4 First Name Child 4 Middle Name Child 4 Last Name Child 4 Date of Birth MM slash DD slash YYYY Client Gender Child 4 Email Child 4 PhoneChild 4's Parent(s)Child 4's Parent(s) *BothProspectSpouseChild 4 Married? Yes No Child 4's Children(Required)Child 4's Children *01234More 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:(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: Enter Additional Questions(Required)Where did you hear about us?(Required)An Email I ReceivedBlog / FacebookInternet / Search EngineLanding Pages – Estate PlanningRadio and TVLink from another web siteMailing / PostcardNewsletterNewspaperOtherReferralApproximate gross value of my estate(Required)I have concerns about a Special Needs family member:(Required) Yes No Are you interested in discussing Long-Term Care & Nursing Home Asset Protection (recommended for anyone over the age of 65)(Required) Yes No Δ
