Legacy Wealth Planning Consultation Form

Date of Consultation*
Date Format: MM slash DD slash YYYY
Status*
- Married
- Single
- Widow
First Name*
Last Name*
Date of Birth*
Date Format: MM slash DD slash YYYY
Untitled*
- Veteran
- U.S. Citizen
Untitled
1st Marriage:*
- Yes
- No
Spouse/Partner’s First Name
Spouse/Partner’s Last Name
Date of Birth
Date Format: MM slash DD slash YYYY
Untitled*
- Veteran
- U.S. Citizen
1st Marriage:*
- Yes
- No
Physical address line 1
Physical address line 2
Physical address city*
Physical address state/province*
State
Physical address zip/postal code*
Phone 1 number*
Office Phone:
Phone 2 number
Email Address*
Spouse’s Email Address

Children’s Full Names	Gender	Date of Birth	Parent(s)	Married (Y/N)	Number of Grand Children

I have concerns about a Special Needs family member:*
- Yes
- No
My 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 the following questions answered before I am ready to proceed with the creation of my plan:

List

What 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*
Please enter a number from 1 to 10.
I want to avoid Living Probate and/or Death Probate*
Please enter a number from 1 to 10.
Make sure Nursing Home costs don’t use up all my assets*
Please enter a number from 1 to 10.
Make sure my wishes are honored regarding life support decisions*
Please enter a number from 1 to 10.
I want to minimize all Death Taxes*
Please enter a number from 1 to 10.
After my death, make sure my estate stays with my children if they get divorced*
Please enter a number from 1 to 10.
Protect my life insurance from Death Taxes*
Please enter a number from 1 to 10.
Protect my estate if my spouse gets remarried after my death*
Please enter a number from 1 to 10.
After my death, protect my estate from my children’s creditors*
Please enter a number from 1 to 10.
Protecting my special needs child after my death*
Please enter a number from 1 to 10.
Funeral planning for my final arrangements and to make it easier for my family*
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*
Signature

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Legacy Wealth Planning Consultation Form

What Really Matters to Me

Permission to Contact

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Schomer Law Group

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