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Estate Planning Information Center

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WhoWe Are
- A Message From Mark Costley
- Meet Our Team
WhatWe Do
WhyWe Do It
- Peace Of Mind
Resources

Legacy Wealth Planning Consultation Form

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

Children's data

Child's Full Name	Gender	Date of Birth	Parent(s)	Married (Y/N)	Number of Grand Children

Children's data

Child's Full Name	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:*
- IRA/Retirement Plans
- Business/Partnerships
- Stocks, Bonds, Mutual Funds
- Life Insurance
- Certificates of Deposit
- In state real estate
- Out of state real estate
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.
Please contact me using the following method:
Signature
Spouse's Signature
CAPTCHA

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Fill out the form below to access to the worksheets and checklists discussed in The Ultimate Caregiver Guide! After submitting this form, you can clic

FIRST NAME*
LAST NAME*
EMAIL*
ADDRESS
ADDRESS 2
CITY
STATE
ZIP CODE
Email
This field is for validation purposes and should be left unchanged.

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