First Name*

Last Name*

Street Address (incl. Apt. no.)*

City*

State*

Zip*

Main phone number*

How many children do you have? (Please enter -0- if none)

What is the value of your personal residence (if you own) (If you do not own, please enter -0-)

Please identify the types of your INCOMESalaryBusinessPensionSocial SecurityRental IncomeInvestmentsOther

Please enter the value of your combined monthly INCOME (approximate) (Enter -0- if none or TBD if unknown)

Please identify the types of your LIQUID ASSETSCashSavingsBrokerage AccountIndividual StocksBondsOther

Please enter the value of your combined LIQUID ASSETS (approximate) (Enter -0- if none or TBD if unknown)

Please identify the types of your OTHER assetsReal EstateInvestmentsBusiness InterestsOther

Please enter the value of your total combined OTHER assets (approximate) (Enter -0- if none or TBD if unknown)

Do you want (or need) to avoid probate?SelectYesNo

Do you want a trusted person to hold & manage your assets for your beneficiaries (such as your spouse or children) in trust, and to make distributions to them only upon the occurrence of certain dates or events, such as when a beneficiary attains a certain age?SelectYesNo

Are you interested in (or do you or a family member need) Asset Protection?SelectYesNo

Are you interested in (or do you need) Medicaid Planning?SelectYesNo

Which of these estate documents do you already have?Last Will TestamentRevocable TrustIrrevocable TrustLife Insurance TrustPower of Attorney (incl. Gifts Rider)Health Care ProxyLiving WillPrenuptial AgreementPostnuptial AgreementOther

Please feel free to let us know about specific issues or concerns you would like us to address in your estate plan