Case Evaluations | Estate Planning Attorney Illinois | Madison Medicaid Planning Community Resources

*Name:

*Address:

*City:

*State:

*Zip:

*E-mail address:

*Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

Are you known by any other names?
YesNo

If yes, list other names you have used:

What is your marital status?

Does this matter involve a business you own or run?
YesNo

If yes, provide the business name, address, and phone:

If a business is involved, how is the business organized (if known)?

Are you employed?
YesNo

If yes, please provide your job title and employer's name and address:

Can you be contacted at work?
YesNo

What area of law does your situation involve (if known)?

Describe your situation, including any relevant dates:

How would you rate your legal needs described here?

Are any other people involved?
YesNo

If yes, provide names, addresses (if known), and their relationship to you, if any:

Do you have any documents that could help explain your situation?
YesNo

If yes, list those documents and their dates:

Are there other documents that you do not have access to that could be of assistance?
YesNo

If yes, list those documents and their dates and location (if known):

Describe how this situation has impacted you:
Describe what you would like to happen to resolve your issue (your preferred outcome):
Have other attorneys worked on this matter? YesNo
If yes, provide names, addresses, and a brief description of their involvement:
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The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for individual advice regarding your own situation.

Copyright © 2008 by Leonard F. Berg. All rights reserved. You may reproduce materials available at this site for your own personal use and for non-commercial distribution. All copies must include this copyright statement.