Legacy Wealth Planning Consultation Form Date of Consultation* Date Format: MM slash DD slash YYYY Status*MarriedSingleWidowFirst Name*Middle InitialLast Name*Date of Birth* Date Format: MM slash DD slash YYYY Untitled* Veteran U.S. Citizen Untitled1st Marriage:*YesNoSpouse/Partner’s First NameMiddle InitialSpouse/Partner’s Last NameDate of Birth Date Format: MM slash DD slash YYYY Untitled* Veteran U.S. Citizen 1st Marriage:*YesNoPhysical address line 1Physical address line 2Physical address city*Physical address state/province* State *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Physical address zip/postal code*County*Phone 1 number*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:*YesNoMy 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 questions answered before I am ready to proceed with the creation of my plan.How Did You Hear About Us*An Email I ReceivedSocial Media/BlogInternet/Search EngineLink From Another WebsiteRadio or TVMailing/PostcardNewsletterNewspaperReferralOtherPermission 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
