Legacy Wealth Planning Consultation Form Pre Consultation Form fillable Date of Consultation* MM slash DD slash YYYY Status* Married Single First Name* Middle Name Last Name* Date of Birth* MM slash DD slash YYYY Untitled* Veteran U.S. Citizen Untitled 1st Marriage:* Yes No Spouse/Partner’s First Name Spouse/Partner’s Last Name Date of Birth MM slash DD slash YYYY Untitled* Veteran U.S. Citizen 1st Marriage:* Yes No Physical address line 1 Physical address line 2 Physical address city* Physical address state/province* State *AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Physical address zip/postal code* Phone 1 number*Office Phone:Phone 2 numberEmail Address* Spouse’s Email Address 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.”) I want to make sure my spouse/partner and I have a written plan to manage our affairs and control how our property is distributed after death*Please enter a number from 1 to 10.I want to avoid Curatorship and Interdiction if I become unable to take care of myself or my finances*Please enter a number from 1 to 10.I want to avoid Probate*Please enter a number from 1 to 10.I want to make sure my spouse/partner is financially protected after my death and has flexibility to deal with changes in our family after I am gone*Please enter a number from 1 to 10.I want to make sure Nursing Home costs don’t use up all my assets*Please enter a number from 1 to 10.I want to make sure my wishes regarding life support decisions are honored*Please enter a number from 1 to 10.I want to minimize Death Taxes*Please enter a number from 1 to 10.I want to protect my life insurance from Death Taxes and creditors*Please enter a number from 1 to 10.I want to make sure my part of our plan is carried out even though my spouse/partner decides to change our plan after my death or becomes incapacitated or gets remarried.*Please enter a number from 1 to 10.I want to protect the property I leave for my children from their creditors and from their spouses if they get divorced after my death*Please enter a number from 1 to 10.I have a special needs child or loved one that I want to protect after my death*Please enter a number from 1 to 10.I want to address funeral planning and my final arrangements*Please enter a number from 1 to 10.OtherPlease enter a number from 0 to 10.What Really Matters to Me (Other) Children’s Full NamesGenderDate of BirthParent(s)Married (Y/N)Number of Grand Children My estate has the following assets:* Land One or more IRAs One or more LLCs Land in more than one state 401(k) or similar Retirement Plan Business/Partnerships Certificates of Deposit Stocks, Bonds, Mutual Funds Life Insurance Do the assets of either or both potential clients have a total value of over $6.2 Million?* Yes No 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 Permission to Contact I prefer to be contacted at* The physical address listed above (don’t email me) The email address listed above Either or both. 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. Signature*SignatureTexting permission I agree to receive texts at the number provided from John Pucheu LLC. Frequency may vary and include information on appointments, events, and other marketing messages. Message/data rates may apply. To opt-out, text STOP at any time. CAPTCHA Δ
