Name

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Email Address

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Phone Number

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Date of Birth

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U.S. Citizen?
yes    no
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Spouse Name

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Date of Birth

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U.S. Citizen?
yes    no
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Address

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County

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City

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State

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Zip

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State of Residence

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What is your marital status?

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Have you or your spouse ever been divorced?
yes    no
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For whom do you want to provide in your Will or Trust?

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If you have children, do you wish to treat all of your children equally?
yes    no
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After your death, at what age do you want distribution to your children, if not immediately?

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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
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If so, how much and to whom?

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At what age, if not immediately?

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Do you want to leave a specific amount of money or other assets to any charity?
yes    no
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If so, how much?

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Name and Address of Charity

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Assets

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

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Legal description

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This property is held as follows
Choose oneIn my individual nameJoint with my spouseAs tenants in common with othersIn another ownership form
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I have debt on this real estate with the following lender(s):

Name

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Address

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Telephone

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Name

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Address

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Telephone

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Asset Value
Personal Property

Checking $

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Savings $

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Cash $

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Bonds $

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Stocks $

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CD's $

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Household Goods/Furnishings $

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Automobile

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Other (list) $

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Real Estate

Home $

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Vacation Home $

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Rental Property $

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Land $

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Outstanding Debts

Mortgage $

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Automobile $

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Credit Cards $

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Medical Expenses $

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Other $

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How did you out about find us?

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If somebody referred you to us, who was it?

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Special Concerns

Asset protection concerns

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Elder law, Medicaid or Nursing Home concerns

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Special needs of family members or other beneficiaries

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Pending lawsuits

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Pending divorce

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Desire to disinherit a family member

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Other concerns

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