LEGACY WEALTH PLANNING CONSULTATION FORM* = Required Date of Consultation* MM slash DD slash YYYY Status* Married Partners Single Widow/Widower First Name (Person 1)* 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 Spouse’s Email Address 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 Cell Phone NumberPhysical 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* Email Address* phone number*Phone Type **Phone Type *Home PhoneCell PhoneOtherHow many children? How many children together?How many children of Person 1?How many children of Person 2? Texting Permission I agree to receive texts at the number provided from Zimmer Law Firm. 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. I have concerns about a Special Needs family member.* Yes No I have a loved one who needs nursing care and would like to talk about protecting their assets.* Yes No My estate has the following assets: Real Estate in Ohio IRA/Retirement Plans Business/Partnerships Real Estate out of Ohio Stocks, Bonds, Mutual Funds Life Insurance Certificates of Deposit Bank Account Approximate gross value of my entire estate*Please check one of the following circles: I am ready to proceed with the creation of my estate plan. I have a loved one who needs nursing care. I am ready to proceed with a plan. I would like general information only. I need the following questions answered before I am ready to proceed with the creation of my plan: Type questions here What Matters Most To MePlease rate the following estate planning concerns on a scale of 1 to 10. One is least important. Ten is most important. (You can repeat numbers)My Estate goes to the heirs I choosePlease enter a number from 1 to 10.Avoid Living Probate and/or Death ProbatePlease enter a number from 1 to 10.Nursing Care Costs will not consume all my assetsPlease enter a number from 1 to 10.Make sure my wishes are honored regarding life support decisionsPlease enter a number from 1 to 10.After my death, make sure my estate stays with my children if they get divorcedPlease enter a number from 1 to 10.Make sure the right people I choose are in charge of my affairsPlease enter a number from 1 to 10.Protect my estate if my spouse gets remarried after my deathPlease enter a number from 1 to 10.After my death, protect my estate from my children’s creditorsPlease enter a number from 1 to 10.Protect my special needs beneficiaryPlease enter a number from 1 to 10.Minimize Death TaxesPlease enter a number from 1 to 10.Plan for special family issues (explain below - optional)Please enter a number from 1 to 10.Explain family issues herePermission to Contact I authorize Zimmer Law Firm to occasionally mail or email information to me and to text message me for appointment reminders. 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. I prefer to be contacted at the phone number and email address listed above.Use your mouse or touch screen to sign. You can also type your name in the box below instead of writing your signature.Signature * Reset signature Signature locked. Reset to sign again Signature * Reset signature Signature locked. Reset to sign again Untitled Untitled Untitled Δ
