1Your Information

2Children

3Additional Information

LinkedIn
This field is for validation purposes and should be left unchanged.
Your Information
First Name *(Required)
Last Name(Required)
Marital Status(Required)
- Married
- Unmarried
Email Address(Required)
Date of Birth *
Client Gender
Spouse/Partner Information
Spouse/Partner’s First Name
Spouse/Partner’s Last Name
Spouse’s Email Address
Spouse/Partner’s Date of Birth
Spouse Gender
Physical Address
Physical address line 1
Physical address line 2
Physical address city
Physical State
State
Physical address zip/postal code
Is your Mailing Address the same as Physical Address?
- My Mailing Address is the same
- My Mailing Address is different. I’d like to enter that address
Mailing Address
Mailing address line 1
Mailing address line 2
Mailing address city
Mailing State
State
Mailing address zip/postal code
Phone Number 1
Phone Number 1 Description
Phone 1 number
Add A Second Number
- Add Another Phone Number
Phone Number 2
Phone Number 2 Description
Phone 2 number
Add A Third Number
- Add Another Phone Number
Phone Number 3
Phone Number 3 Description
Phone 3 number

Health Care Matters
Your Health Care Matters

In the event you become disabled, who do you want to make health care decisions for you in your Health Care Power of Attorney and Advance Directive? Name at least two people.
Contact 1:
Individuals to serve in this order:
- [✓] Select

Contact 1 List

Individuals to serve jointly:
- [✓] Select

Jointly Serving Individuals 1

1. &	2.	3. &	4.

Authority of health care agents 1
- Either person may act alone without the other’s approval (A “and/or” B)
- The named persons must agree on all actions (A “and” B)
Contact 2:
Individuals to serve in this order:
- [✓] Select

Contact 2 List

Individuals to serve jointly:
- [✓] Select

Jointly Serving Individuals 2

1. &	2.	3. &	4.

Authority of health care agents 2
- Either person may act alone without the other’s approval (A “and/or” B)
- The named persons must agree on all actions (A “and” B)
Treating Physician/ Contact 1
Contact 1 Physician Name
First Name Last Name
Contact 1 Physician Address
Street Address City State ZIP Code
Contact 1 Physician Phone Number
Treating Physician/ Contact 2
Contact 2 Physician Name
First Name Last Name
Contact 2 Physician Address
Street Address City State ZIP Code
Contact 2 Physician Phone Number

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.”)
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.”)
Make sure there’s a written plan to handle my affairs
Please enter a number from 1 to 10.
Make sure Nursing Home costs don’t use up all my assets
Please enter a number from 1 to 10.
Make sure my wishes are honored regarding life support decisions
Please enter a number from 1 to 10.
I want to minimize all Death Taxes
Please enter a number from 1 to 10.
After my death, make sure my estate stays with my children if they get divorced
Please enter a number from 1 to 10.
Protect my life insurance from Death Taxes
Please enter a number from 1 to 10.
Protect my estate if my spouse gets remarried after my death
Please enter a number from 1 to 10.
After my death, protect my estate from my children’s creditors
Please enter a number from 1 to 10.
Protecting my special needs child after my death
Please enter a number from 1 to 10.
Funeral planning for my final arrangements and to make it easier for my family
Please enter a number from 1 to 10.
Agreement
I agree to receive texts at the number provided from Parman & Easterday. 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.

Legacy Wealth Planning Pre-Consultation Form

Your Information

Spouse/Partner Information

Physical Address

Mailing Address

Phone Number 1

Phone Number 2

Phone Number 3

Child 1

Child 2

Child 3

Child 4

Additional Children Information

Additional Information

Financial Management

Health Care Matters

What Really Matters to Me

Name	Name	Name