Legacy Wealth Planning Pre-Consultation Form 1Your Information2Children3Additional Information Your InformationFirst Name *(Required)Middle NameLast Name(Required)Email Address(Required) Date of Birth * Client GenderSelect GenderMaleFemaleMarital Status(Required) Married Unmarried Spouse/Partner InformationSpouse/Partner’s First NameSpouse/Partner’s Middle NameSpouse/Partner’s Last NameSpouse’s Email Address Spouse/Partner’s Date of Birth Spouse GenderSelect GenderMaleFemalePhysical AddressPhysical address line 1Physical address line 2Physical address cityPhysical StatePhysical 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 PacificPhysical address zip/postal codeIs your Mailing Address the same as Physical Address? My Mailing Address is the same My Mailing Address is different. I’d like to enter that address Mailing AddressMailing address line 1Mailing address line 2Mailing address cityMailing State 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 codePhone Number 1Phone Number 1 DescriptionDescriptionHomeMobileOtherPhone 1 numberAdd A Second Number Add Another Phone Number Phone Number 2Phone Number 2 DescriptionDescriptionHomeMobileOtherPhone 2 numberAdd A Third Number Add Another Phone Number Phone Number 3Phone 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 1Child 1 First NameChild 1 Middle NameChild 1 Last NameChild 1 Date of Birth Child 1 GenderSelect GenderMaleFemaleChild 1 Email Child 1 PhoneChild 1's Parent(s)Child 1's Parent(s)BothProspectSpouseChild 1's ChildrenChild 1's Children01234More than 4Child 1 Married? Yes No Child 2Child 2 First NameChild 2 Middle NameChild 2 Last NameChild 2 Date of Birth Child 2 GenderSelect GenderMaleFemaleChild 2 Email Child 2 PhoneChild 2's Parent(s)Child 2's Parent(s)BothProspectSpouseChild 2's ChildrenChild 2's Children01234More than 4Child 2 Married? Yes No Child 3Child 3 First NameChild 3 Middle NameChild 3 Last NameChild 3 Date of Birth Child 3 GenderSelect GenderMaleFemaleChild 3 Email Child 3 PhoneChild 3's Parent(s)Child 3's Parent(s)BothProspectSpouseChild 3's ChildrenChild 3's Children01234More than 4Child 3 Married? Yes No Child 4Child 4 First NameChild 4 Middle NameChild 4 Last NameChild 4 Date of Birth Child 4 GenderSelect GenderMaleFemaleChild 4 Email Child 4 PhoneChild 4's Parent(s)Child 4's Parent(s)BothProspectSpouseChild 4's ChildrenChild 4's Children01234More than 4Child 4 Married? Yes No Additional Children InformationEnter Additional Children Information My estate has the following assets:Real Estate Check Real Estate Real EstateAddressEstimated ValueWhose Name is It In? Checking/Savings Account Check Checking/Savings Account Checking/Savings AccountInstitution NameEstimated ValueWhose Name is It In? Certificates of Deposit Check Certificates of Deposit Certificates of DepositInstitution NameEstimated ValueWhose Name is It In? Stocks, Bonds, Mutual Funds Check Stocks, Bonds, Mutual Funds Stocks, Bonds, Mutual FundsInstitution NameEstimated ValueWhose Name is It In? IRA/Retirement Plans Check IRA/Retirement Plans IRA/Retirement PlansInstitution NameEstimated ValueWhose Name is It In? Time Share Check Time Share Time ShareInstitution NameEstimated ValueWhose Name is It In? Life Insurance Check Life Insurance Life InsuranceInstitution NameEstimated ValueWhose Name is It In? Business/Partnerships Check Business/Partnerships Business/PartnershipsInstitution NameEstimated ValueWhose Name is It In? Property Lease Check Property Lease Property LeaseInstitution NameEstimated ValueWhose Name is It In? Intellectual Property Interest (Patent) Check Intellectual Property Interest (Patent) Intellectual Property Interest (Patent)Institution NameEstimated ValueWhose Name is It In? Oil & Gas Interests Check Oil & Gas Interests Oil & Gas InterestsInstitution NameEstimated ValueWhose Name is It In? Lawsuit Judgements You Have Been Awarded Check Lawsuit Judgements You Have Been Awarded Lawsuit Judgements You Have Been AwardedInstitution NameEstimated ValueWhose Name is It In? Approximate gross value of my estateI have concerns about a Special Needs family member: Yes No Please confirm if you watched our recorded seminar. Yes No If you have any questions, please call our office.
