Thank you for your interest in estate planning with Walsh Estate and Family Law. We are looking forward to assisting you in providing peace of mind for you and your family. So that we may provide you with efficient and accurate service, please fill out the following questionnaire as thoroughly as possible. Information collected here is maintained
securely
and
confidentially
. If you have any questions, feel free to reach out to us for help.
Demographic Information
Contact information: Client Name
Prefix
First name
*
Middle name
Last name
*
Date of birth
Company
Emails
Address
*
Type
Upon submission, a copy of this form will be sent to the primary email.
Work
Home
Other
Primary
Default email false
Add email
Addresses
Street address
Country
Australia
Canada
United Kingdom
United States
---------------
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czechia
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
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Western Sahara
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Zambia
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State/Region
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Virgin Islands, U.S.
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Province/Region
Zip/Postal code
Address type
Work
Billing
Home
Other
Primary
Default address false
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Phone numbers
Phone number
Type
Work
Home
Mobile
Fax
Pager
Skype
Other
Primary
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Please let us know your interst in any of the following:
Draft a Last Will and Testament
Review or Amend an Existing Will
Family Trust
General Power of Attorney
Health Care Power of Attorney
Living Will
Special Needs Trust
Guardianship
How many years have you been a resident of North Carolina?
Select an option
0-2
3-6
7+
What is your current marital status?
Single
Married
What is your current spouse's name?
How many children are in your family?
None (0)
One (1)
Full name:
Date of birth:
Two (2)
Child #1 Full name:
Child #1 Date of Birth:
Child #2 Full Name
Child #2 Date of Birth
Three (3)
Child #1 Full Name
Child #1 Date of birth:
Child #2 Full Name:
Child #2 Date of birth:
Child #3 Full name
Child #3 Date of birth:
Four (4)
Child #1 Full name:
Child #1 Date of birth:
Child #2 Full name:
Child #2 Date of birth:
Child #3 Full name:
Child #3 Date of birth
Child #4 Full name:
Child #4 Date of birth:
Five or more (5+)
Please provide the full names and dates of birth for your children:
Do any members of your immediate family have special needs?
Yes
No
Please identify two or three people you would want to act on your behalf in the event of your incapacity:
Please tell us anything else you would like us to know about your estate planning objectives.