How did you hear about my office?

Are you a U.S. citizen?

Select an option Yes No

Do you currently reside in Illinois?

Select an option Yes No

What is your current marital status?

Select an option Single Married Separated Civil Union Divorced Widowed

If you are married, separated, or in a civil union, what is the name of your spouse / partner?

If you are married, separated, or in a civil union, is your spouse / partner a U.S. citizen?

Select an option Yes No

If you are married, separated, or in a civil union, does your spouse / partner currently reside in Illinois?

Select an option Yes No

If you are married, separated, or in a civil union, have you or your spouse / partner ever been previously married?

Select an option Yes No

Do you or a spouse / partner have children from a previous relationship?

Select an option Yes No

Do you or a spouse / partner have any children or beneficiaries with special needs?

Select an option Yes No

Do you or a spouse / partner have any estate planning documents that are currently in effect?

Select an option Yes No

If yes, please select the documents that are currently in effect (check all that apply):

Will(s)Trust(s)Power(s) of attorney for propertyPower(s) of attorney for health careHIPAA authorization(s)Other

In order to evaluate preliminary tax and probate exposure, what is your approximate household net worth (include both you and your spouse / partner, if relevant)?

Select an option $0 - $500,000 $500,001 - $1,000,000 $1,000,001 - $2,000,000 $2,000,001 - $3,000,000 $3,000,001 - $4,000,000 $4,000,001 - $5,000,000 $5,000,001 - $6,000,000 $6,000,001 - $7,000,000 $7,000,001 - $8,000,000 Over $8,000,000

Do you or a spouse / partner own any of the following? (check all that apply)

Real estate outside of IllinoisA business entity, LLC, or partnership interestCryptocurrency

What is your primary motivation for creating your estate plan at this time?

Select an option General peace of mind Upcoming travel Recent health diagnosis New child / grandchild

When would you ideally like your documents completed and signed?

Select an option I have an urgent need to get this completed as soon as possible No specific time frame but within a reasonable time period I'm just exploring options

REQUIRED ACCEPTANCE AND ACKNOWLEDGMENT: I acknowledge that I have read and hereby accept the above privacy policy regarding the use of my personal information. I also have read and hereby accept the above notice that, in addition to his law practice at Jeffrey R. Van Dyke, LLC, Jeffrey R. Van Dyke also acts as an "Of Counsel" attorney with the estate planning law practice of the Kabbe Law Group, LLC in Naperville, Illinois. In submitting these responses, I understand and agree that this information and any relevant documentation may be shared with both law practices. I understand that no attorney-client relationship is formed between me and Jeffrey R. Van Dyke, LLC or the Kabbe Law Group, LLC by submitting my responses. An attorney-client relationship will only be established by a formal, written representation agreement. Nothing within this form constitutes legal advice.

Select an option AGREED

Thank you!