Legacy Wealth Planning Consultation Form Date of Consultation(Required) MM slash DD slash YYYY Status(Required) Married Single Widow First Name(Required) Last Name(Required) Date of Birth(Required) MM slash DD slash YYYY Untitled(Required) Veteran U.S. Citizen Untitled 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 *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’s Full NamesGenderDate 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. CAPTCHA Δ
