Estate Planning Contact Form

Name

Email Address

Phone Number

Date of Birth

U.S. Citizen?
Yes  No 

Spouse Name

Date of Birth

U.S. Citizen?
Yes  No 

Address

County

City

State

Zip

State of Residence

What is your marital status?

Have you or your spouse ever been divorced?
Yes  No 

For whom do you want to provide in your Will or Trust?

If you have children, do you wish to treat all of your children equally?
Yes  No 

After your death, at what age do you want distribution to your children, if not immediately?

If you have grandchildren, do you wish to leave a specific amount of money or a percentage of your estate to your grandchildren?
Yes  No 

If so, how much and to whom?

At what age, if not immediately?

Do you want to leave a specific amount of money or other assets to any charity?
Yes  No 

If so, how much?

Name and Address of Charity

Assets

I own the following real estate (provide address/addresses)

Legal description

This property is held as follows
Choose Onein my individual namejoint with my spouseas tenants in common with othersin another ownership form

I have debt on this real estate with the following lender(s):

Name

Address

Telephone

Name

Address

Telephone

Asset Value

How did you out about find us?

If somebody referred you to us, who was it?

Special Concerns

Asset protection concerns

Elder law, Medicaid or Nursing Home concerns

Special needs of family members or other beneficiaries

Pending lawsuits

Pending divorce

Desire to disinherit a family member

Other concerns

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