LEGACY WEALTH PLANNING CONSULTATION FORM Date of Consultation(Required) MM slash DD slash YYYY Status(Required) Married Single First Name(Required) Last Name(Required) Date of Birth(Required) MM slash DD slash YYYY Untitled(Required) Veteran U.S. Citizen 1st Marriage:(Required) Yes No Spouse/Partner’s First Name Spouse/Partner’s Last Name Date of Birth MM slash DD slash YYYY Untitled(Required) Veteran U.S. Citizen 1st Marriage:(Required) Yes No Physical address line 1 Physical address line 2 Physical address city(Required) Physical address state/province(Required) 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(Required) Phone 1 number(Required)Office Phone:Phone 2 number(Required)Email Address(Required) Spouse’s Email Address(Required) Children’s Full NamesSexDate of BirthParentMarried (Y/N)Number of Grand Children Add RemoveI have concerns about a Special Needs family member:(Required) Yes No My estate has the following assets:(Required) Real Estate IRA/Retirement Plans Business/Partnerships Stocks, Bonds, Mutual Funds Life Insurance Certificates of Deposit 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 Add RemoveWhat Really Matters to MePlease check the box(es) corresponding with your estate planning goals and concerns: Make sure there’s a written plan to handle my affairs I want to avoid Living Probate and/or Death Probate Make sure Nursing Home costs don’t use up all my assets Make sure my wishes are honored regarding life support decisions I want to minimize all Death Taxes After my death, make sure my estate stays with my children if they get divorced Protect my life insurance from Death Taxes Protect my estate if my spouse gets remarried after my death After my death, protect my estate from my children’s creditors Protecting my special needs child after my death Funeral planning for my final arrangements and to make it easier for my family Permission 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(Required)Signature(Required)