<html>

<head>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1">
<title>Estate Planning </title>
<meta name="GENERATOR" content="Microsoft FrontPage 3.0">
</head>

<body>

<p align="center">&nbsp;</p>

<p align="center"><img src="header.jpg" WIDTH="501" HEIGHT="113"> </p>
<div align="center"><center>

<table width="600">
  <tr>
    <td><p align="center"><br>
    </p>
    <p align="center"><img src="ep.gif" WIDTH="568" HEIGHT="97"></p>
    <h3 align="center">Estate Planning - Asset Protection Consultation Request</h3>
    <p>Please complete the following confidential request form to receive <b>FREE</b>
    information on Estate Planning &amp; Wealth Preservation Strategies. Please note: <b>All
    fields must be completed</b>. </p>
    <form action="/cgi-bin/ffmltd.pl" method="post">

    <input type="hidden" name="attorney_name" value="<? echo $attorney_name?>">
    <input type="hidden" name="attorney_state" value="<? echo $attorney_state ?>">

      <input type="hidden" name="missing_fields_redirect" value="/oops.html"><input type="hidden" name="recipient" value="info@fielder.com"><input type="hidden" name="redirect" value="/thankyou.html"><input type="hidden" name="required" value="Name,Address,City,State,Zip Code,Email,Home Phone,Business Phone"><input type="hidden" name="subject" value="Estate Planning - Consultation Request"><pre>
  Name:         <input type="text" size="30" name="Name">  
  Address:      <input type="text" size="30" name="Address">
  City:         <input type="text" size="30" name="City">  State/Province: <input type="text" size="5" name="State">
  Zip Code:     <input type="text" size="5" name="Zip Code">
  Email:        <input type="text" size="30" name="Email">
  Home Phone:   <input type="text" size="12" name="Home Phone">  
  Work Phone:   <input type="text" size="12" name="Business Phone">
  Your Age:     <input type="text" size="5" name="Age">
  Spouse's Age: <input type="text" size="5" name="Spouse's Age">

  I am most interested in: <select name="Topic" size="1"><option value="Free Estate Analysis">Free Estate Analysis</option><option value="Living Trust">Living Trust</option><option value="Tax Free Inheritance Trust (Irrevocable Trust)">Tax Free Inheritance Trust (Irrevocable Trust)</option><option value="Gifting Strategies">Gifting Strategies</option><option value="Family Limited Partnership">Family Limited Partnership</option><option value="Capital Gains By-Pass Trust (Charitable Remainder Trust)">Capital Gains By-Pass Trust (Charitable Remainder Trust)</option><option value="Charitable Split Dollar">Charitable Split Dollar</option><option value="Foundation">Foundation</option><option value="Unsure, Please Help!!">Unsure, Please Help!!</option></select>
  			     
  Your Estate is valued at approximately: <select name="Estate Value" size="1"><option value="$600,000 to $1,000,000">$600,000 to $1,000,000</option><option value="$1,000,000 to $3,000,000">$1,000,000 to $3,000,000</option><option value="$3,000,000 to $5,000,000">$3,000,000 to $5,000,000</option><option value="$5,000,000 to $10,000,000">$5,000,000 to $10,000,000</option><option value="Above $10,000,000">Above $10,000,000</option></select>
  
  Your occupation is: <input type="text" size="40" name="Occupation">

  I currently have a:
    <input type="checkbox" name="Currently have..." value="Will"> Will                 <input type="checkbox" name="Currently have..." value="Living Trust"> Living Trust        <input type="checkbox" name="Currently have..." value="Irrevocable Trust"> Irrevocable Trust
    <input type="checkbox" name="Currently have..." value="Family Partnership"> Family Partnership   <input type="checkbox" name="Currently have..." value="Family Foundation"> Family Foundation   <input type="checkbox" name="Charitable Remainder Trust" value="ON"> Charitable Remainder Trust
    Other, please specify: <input type="text" size="30" name="Currently have...">
  
  Your time frame to implement such a plan is:
    <input type="radio" name="Time Frame" value="Less than one month"> Less Than One Month   <input type="radio" name="Time Frame" value="1 to 3 months"> 1 To 3 Months   <input type="radio" name="Time Frame" value="3 to 6 months"> 3 To 6 Months

  
  Additional Comments/Questions for <strong><? echo $attorney_name ?></strong>:
  <textarea cols="60" rows="5" name="Comments">
</textarea>

  <input type="submit" value="Submit"> <input type="reset" value="Clear Form">
</pre>
    </form>
    </td>
  </tr>
</table>
</center></div>

<p align="center"><font size="-1" face="arial, geneva, helvetica">Copyright © 1998
Fielder Financial Management, Ltd. <br>
All Rights Reserved. </font></p>
</body>
</html>
