Legacy Wealth Planning Consultation Form

Address: 1414 Raleigh Road, Suite 445, Chapel Hill, NC 27517, US
Telephone: 919-484-0012

Date of Consultation*
Date Format: MM slash DD slash YYYY
Status*
- Married
- Single
Date of Birth*
Date Format: MM slash DD slash YYYY
First Name*
Middle Name
Last Name*
Untitled*
- Veteran
- U.S. Citizen
1st Marriage:*
- Yes
- No
Spouse/Partner’s First Name
Spouse/Partner’s Middle 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
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 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:*
- 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

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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 click to download any of the worksheets listed here. Thank you!

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

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

Legacy Wealth Planning Consultation Form

What Really Matters to Me

Permission to Contact

Fill out the form below to access to the worksheets and checklists discussed in The Ultimate Caregiver Guide! After submitting this form, you can click to download any of the worksheets listed here. Thank you!