EmailMe Form - Estate Planning Organizer

Spouse 1

First Last

Date of Birth

MM / DD / YYYY

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Telephone

### - ### - ####

Fax

### - ### - ####

Cell Phone

### - ### - ####

Preferred method of contact

Telephone

Cell Phone

E-mail

Written Correspondence send to

Home

Business

Other

If written correspondence is to be sent to an address other than your home or business address specify address below

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Social Security Number

U.S. Citizen

Yes

No

Status of Health

Good

Fair

Poor

Please describe health conditions

Business/ Employer

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Marital Status

Single / Widow

Married

Divorced

If currently married, please ensure that you provide your Spouse's information ( Section 2)

Country / State where marraige was performed

Children from this marraige

Child

First Last

Date of Birth

MM / DD / YYYY

Child

First Last

Date of Birth

MM / DD / YYYY

Child

First Last

Date of Birth

MM / DD / YYYY

Child

First Last

Date of Birth

MM / DD / YYYY

Child

First Last

Date of Birth

MM / DD / YYYY

Any disabilities in the immediate family?

Please describe

Children From Prior Relationship?

Yes

No

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