Legacy Wealth Planning Consultation Form Δ NameThis field is for validation purposes and should be left unchanged.Date of Consultation(Required) Status(Required) Married Single Widow First Name(Required)Last Name(Required)Date of Birth(Required) Untitled(Required) Veteran U.S. Citizen Untitled1st Marriage *:(Required) Yes No Spouse/Partner’s First NameSpouse/Partner’s Last NameDate of Birth Untitled(Required) Veteran U.S. Citizen 1st Marriage *:(Required) Yes No Physical address line 1Physical address line 2Physical address city(Required)Physical address state/province(Required) 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 Pacific State Physical address zip/postal code(Required)Phone 1 number(Required)Office Phone:Phone 2 numberEmail Address(Required) Spouse’s Email Address Children First NameChildren Last NameGenderDate of BirthParent(s)Married (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 Bank Account 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 Me 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 affairs *(Required)Please enter a number from 1 to 10.I want to avoid Living Probate and/or Death Probate *(Required)Please enter a number from 1 to 10.Make sure Nursing Home costs don’t use up all my assets *(Required)Please enter a number from 1 to 10.Make sure my wishes are honored regarding life support decisions *(Required)Please enter a number from 1 to 10.I want to minimize all Death Taxes *(Required)Please enter a number from 1 to 10.After my death, make sure my estate stays with my children if they get divorced *(Required)Please enter a number from 1 to 10.Protect my life insurance from Death Taxes *(Required)Please enter a number from 1 to 10.Protect my estate if my spouse gets remarried after my death *(Required)Please enter a number from 1 to 10.After my death, protect my estate from my children’s creditors *(Required)Please enter a number from 1 to 10.Protecting my special needs child after my death *(Required)Please enter a number from 1 to 10.Funeral planning for my final arrangements and to make it easier for my family *(Required)Please enter a number from 1 to 10.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)SignatureTexting Permission I agree to receive texts at the number provided from Wilcox Attorneys, PA. Frequency may vary and include information on appointments, events, and other marketing messages. Message/data rates may apply. To opt-out, text STOP at any time.
