Legacy Wealth Planning Consultation Form

Children’s Full Names	Gender	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

Please use this section to add your estate planning concerns
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 **
Spouse's Signature

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