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Consultation Application (Individual)
In preparation for your upcoming consultation, please complete the following application as completely as possible. Since your time together over the phone is limited, having this information prepared prior to your consultation will allow Ms. Amrine to make the best use of your time and evaluate your situation. Please also email/upload copies of any of the additional items listed below that you may have : - Latest bank/investment statements - Copy of deed to real property (or property tax bill) - If applicable, Military discharge papers (DD-214) - Any life or long term care insurance policies, - Current Estate Plan Documents *In-Person Consultation Only: If you do not have access/ability to scan and email these documents prior to your consultation, please prepare and bring copies of your documents to our office.
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Thailand
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Tokelau
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Turkey
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Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
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United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
*
Date of Birth (DOB:
*
MM
DD
YYYY
Age
*
Social Security Number (SSN):
*
Occupation:
*
Employer's Name
Employer's Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
USA
Afghanistan
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
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
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 and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
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
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Are you a US Military Veteran?:
*
Yes
No
Email Address:
*
Name of closest Relative NOT living with you:
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
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First
Last
Suffix
Closest Relative's Relationship to you:
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Closest Relative's Address:
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Street Address
Address Line 2
City
CA
Alabama
Alaska
Arizona
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California
Colorado
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District of Columbia
Florida
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Iowa
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
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New Mexico
New York
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Tennessee
Texas
Utah
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Virginia
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Armed Forces Europe
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Closest Relative's Phone Number:
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How did you hear about Amrine Law?:
*
Legal consultation services by Amrine Law, hereinafter called "attorney", are rendered upon the following terms and conditions: 1. All costs and necessary disbursements, incurred by Attorney in advancing cause are to be borne by client in addition to fees for legal services. 2. Client agree that statements for legal consultation services and costs are due and payable upon receipt, unless other arrangements have been made. 3. Attorney is authorized at Attorney's sole discretion to disclose any and all information to any person whomsoever in the furtherance of client's cause. Attorney may communicate with client of others by email which may be in unencrypted form unless client notify Attorney in writing to the contrary. 4. Client understands that Attorney has made and will make no promise or guarantee regarding the outcome of any matter for which legal services are sought by client. 5. In the processing of client's case, Attorney may utilize secretaries, paralegals, law clerks and other non-counsel personnel of Attorney's choosing. 6. Client will be billed for consultation services at the following rates: Attorney Amrine: $350/hour. 7. This is an agreement for CONSULTATION ONLY. This application does not obligate Attorney, a) to accept the case, or b) to perform legal services and does not constitute a contract between the applicant and Attorney.
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