Required fields are marked with a *
Personal Information
Full Name *
Email Address *
Telephone *
Date of Birth
U.S. Citizen?
Yes No
Address
Zip *
Incident Details
Incident Address
Incident Zip *
Marital Details
What is your marital status?
Spouse's Name
Spouse's Date of Birth
Is your spouse a U.S. citizen?
Yes No
Spouse's state of residence
Have you or your spouse ever been divorced?
Yes No
Will & Trust Distribution
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 N/A
After your death, at what age do you want distribution to your children, if not immediately?
Will & Trust Distribution - Grandchildren
If you have grandchildren, do you wish to leave a specific amount of money or a percentage of your estate to them?
Yes No N/A
If so, how much and to whom?
At what age, if not immediately?
Will & Trust Distribution - Charities
Do you want to leave a specific amount of money or other assets to any charities?
Yes No
If so, how much and to whom?
Name and addresses of charities
Assets
I own the following real estate (addresses)
Legal description
The property is held as follows
--- In my individual name Joint with my spouse As tenants in common with others In another ownership form
I have debt on this real estate with the following lender(s). Include names, addresses and telephone numbers.
Asset Value
Personal Property
Real Estate
Outstanding Debts
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
Referrals
How did you find out about us?
If someone referred you to us, who was it?
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