1Your Information2Children3Additional Information Your InformationFirst Name *(Required) Last Name(Required) Marital Status(Required) Married Unmarried Email Address(Required) Date of Birth * MM slash DD slash YYYY Client GenderSelect GenderMaleFemaleSpouse/Partner InformationSpouse/Partner’s First Name Spouse/Partner’s Last Name Spouse’s Email Address Spouse/Partner’s Date of Birth MM slash DD slash YYYY Spouse GenderSelect GenderMaleFemalePhysical AddressPhysical address line 1 Physical address line 2 Physical address city Physical 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 code Is 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 1 Mailing address line 2 Mailing address city Mailing 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 code Phone 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 Name Child 1 Last Name Child 1 Date of Birth MM slash DD slash YYYY Child 1 GenderSelect GenderMaleFemaleChild 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 Children01234More than 4Child 2Child 2 First Name Child 2 Last Name Child 2 Date of Birth MM slash DD slash YYYY Child 2 GenderSelect GenderMaleFemaleChild 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 Children01234More than 4Child 3Child 3 First Name Child 3 Last Name Child 3 Date of Birth MM slash DD slash YYYY Child 3 GenderSelect GenderMaleFemaleChild 3 Email Child 3 PhoneChild 3's Parent(s)Child 3's Parent(s)BothProspectSpouseChild 3 Married? Yes No Child 3's ChildrenChild 3's Children01234More than 4Child 4Child 4 First Name Child 4 Last Name Child 4 Date of Birth MM slash DD slash YYYY Child 4 GenderSelect GenderMaleFemaleChild 4 Email Child 4 PhoneChild 4's Parent(s)Child 4's Parent(s)BothProspectSpouseChild 4 Married? Yes No Child 4's ChildrenChild 4's Children01234More 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: 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 QuestionsApproximate gross value of my estate$0-50,000$50,001-100,000$100,001 – 150,000$150,001 – 200,000Over $200,000I have concerns about a Special Needs family member: Yes No What Really Matters to MePlease 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.”)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 affairsPlease enter a number from 1 to 10.Make sure Nursing Home costs don’t use up all my assetsPlease enter a number from 1 to 10.Make sure my wishes are honored regarding life support decisionsPlease enter a number from 1 to 10.I want to minimize all Death TaxesPlease enter a number from 1 to 10.After my death, make sure my estate stays with my children if they get divorcedPlease enter a number from 1 to 10.Protect my life insurance from Death TaxesPlease enter a number from 1 to 10.Protect my estate if my spouse gets remarried after my deathPlease enter a number from 1 to 10.After my death, protect my estate from my children’s creditorsPlease enter a number from 1 to 10.Protecting my special needs child after my deathPlease enter a number from 1 to 10.Funeral planning for my final arrangements and to make it easier for my familyPlease enter a number from 1 to 10. Δ
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