The Law Office of Jack E. Brackney

Attorney and Counselor at Law

(877) 679-5225
jack@brackneylawoffice.com

39-20 59th Street, Suite 2
Woodside, New York 11377

815 Superior Avenue East, Suite 1618

Cleveland, Ohio 44114

Thank you so much for contacting our law office! Please read the privacy policy below, and then fill out this form in its entirety prior to our consultation. The more Information provided, the more productive your consultation will be.

All information received from a client is strictly confidential. Our firm takes every step possible to protect your privacy. The data submitted via this form is encrypted and secured using industry-standard 256-bit SSL encryption.

Your Social Security Number and other personal information will only be used in the event that you hire the firm to represent you in your legal matter, and then only when necessary in limited use during the course of your case.

Social Security Numbers are most often used to positively identify parties. Most courts require Social Security Numbers of all parties in a case. Some other examples of how this information may be used include:

initial service
in court orders
in required reports or other documents filed with the State

If you have any questions, please don't hesitate to contact our law office. We look forward to working with you!

Contact information: Your Information

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.

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Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

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Phone numbers

Phone number

Type

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Social Security Number

Highest level of education:

Employer Name

Employer Address

Employer Phone Number

Your Annual Gross Income:

Any additional income:

Do you expect any substantial gifts or inheritances in the future?

Yes

Is this agreement made in anticipation of marriage?

Yes

Previous marriage(s) ended by death?

Yes

Mutual waiver of rights in each other's estates?

Yes

Previous marriage(s) ended by divorce?

Yes

Do you have a health care proxy?

Yes

Do you have a will?

Yes

Your Separate Bank Accounts: Value and type of account (checking, savings, etc.)

Real estate owned separately:

Retirement Accounts: Value and type of account (401(k), IRA, HSA, etc.)

Other assets: (vehicles, etc.)

Debts: Lender and Amount (Include Auto, Student Loans, and Credit Cards)

Future Spouse's Information

Name

Date of Birth

Social Security number

Address

Phone Number

Future Spouse's Email Address

Employer Name

Employer Address

Does your future spouse voluntarily agree to the prenuptial agreement?

Yes

Employer Phone Number

Future Spouse's Annual Gross Income:

Does your future spouse expect any substantial gifts or inheritances in the future?

Yes

Highest level of education:

Previous marriage(s) ended by death?

Yes

Previous marriage(s) ended by divorce?

Yes

Is your future spouse represented by an attorney?

Yes

Does your future spouse have a health care proxy?

Yes

Does your future spouse have a will?

Yes

Your future spouse's separate bank accounts: Value and type of account (checking, savings, etc.)

Real estate owned separately:

Retirement Accounts: Value and type of account (401(k), IRA, HSA, etc.)

Other assets: (vehicles, etc.)

Debts: Lender and Amount (Include Auto, Student Loans, and Credit Cards)

Marriage Information

Approximate date you met future spouse:

Approximate date you began dating future spouse:

Approximate date you became engaged to future spouse:

Date of Marriage

Place of Marriage (City, County, State)

Currently reside together?

Yes

Are there children under 21 in either household?

Yes

Do either of you have any former names?

Yes

Additional Information

Approximate value of your separate property?

Approximate value of your future spouse’s separate property?

Do you wish to waive your rights and your future spouse’s rights to the increase in value of separate property?

Yes

Do you wish to waive rights to one another’s inheritances?

Yes

Do you wish to waive your rights and your future spouse’s rights to spousal support?

Yes

Do you and/or your future spouse wish to waive rights to request costs and fees from one another if divorced?

Yes

Do you plan to share joint bank accounts during your marriage?

Yes

Do you each wish to keep your individual earnings separate?

Yes

Do you intend to have children?

Yes

Does either parent plan to stay home with the children?

Yes

Do you wish to make an agreement regarding filing for taxes jointly or separately?

Yes

Do you wish to make an agreement regarding which party will pay for any joint tax liabilities?

Yes

Please set forth which expenses and/or debts you will share during your marriage and the percentage each party will pay.

Please set forth which expenses and/or debts each party will be individually responsible to pay from his or her own funds.

Where will you primarily reside?

Who owns/will own the residence?

Who will own the residence in the event of divorce/death?

How do you wish to provide for one another in your wills/estate plans?

What are your plans regarding medical, disability, life or long-term care insurance?

Is there to be any agreement for either party to maintain life insurance?

Yes

Is there to be any agreement regarding either party’s incompetency or disability during the marriage?

Yes

Please list any other agreements to be included:

Please attach any other documents you feel are important or relevant to our initial discussion. (i.e. court documents, custody petitions or agreements, letters or other correspondence, etc.)

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Thank You!

If you have any written documents that are not attached here, please email those documents to jack@brackneylawoffice.com.

We value each potential client who contacts us and will make arrangements to meet or speak with you when convenient, including Saturdays. Please be advised, however, that The Law Office of Jack E. Brackney is not your legal counsel until there is a signed fee agreement in place between you and the firm. By submitting this form, you are requesting that we evaluate your legal issue. We have not agreed to act as your legal counsel.