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Client Information

Full Name

Address

City

State

ZIP

County of Residence

Email Address

Phone Home

Phone Cell

Employer

Occupation

Family History

Marital Status

If there were any children born during your current marriage, please complete the following:

Child’s name

Sex

Birthdate

Home Address

Telephone

Child’s name

Sex

Birthdate

Home Address

Telephone

Child’s name

Sex

Birthdate

Home Address

Telephone

Are all children born during the marriage of both Husband and Wife?

Is it possible that the Husband and Wife will have or adopt more children?

Have you been married before?

Estate Planning

Do you currently have a will?

Please explain how you would like your estate to be divided:

Executor

Who do you want to name as the executor of your estate?

The executor is the personal representative who will windup your affairs, pay remaining debts and distribute property to the person(s)/trust(s) in your Will. This can be your friend, spouse, child (over 18), etc.

Full Name

Relationship

Home address:

Telephone

First Alternate Executor

Full Name

Relationship

Home address:

Telephone

Second Alternate Executor

Full Name

Relationship

Home address:

Telephone

Trustee

Who do you want to name as the Trustee of your children’s trusts for children under the age of 25 years old?

Generally, spouse first. The Trustee is the personal representative who will be in charge of holding the money for your children and distributing it to them for all their needs.

Full Name

Relationship

Home address:

Telephone

First Alternate Trustee

Full Name

Relationship

Home address:

Telephone

Second Alternate Trustee

Full Name

Relationship

Home address:

Telephone

Guardian Of Minor Child(REN)

Who do you want to name as guardian of your minor child(ren) if applicable?

Technically, there are two types of Guardians: (1) the Guardian of the Person, who is responsible for housing the child and taking care of personal needs and; (2) the Guardian of the Estate, who is responsible for the child’s finances and property. The child’s other biological parent will most likely be appointed Guardian; however, if the other biological parent is not appointed, is deceased or is unwilling to be the child’s Guardian, an alternate choice may be necessary.

Full Name

Relationship

Home address:

Telephone

First Alternate Trustee

Full Name

Relationship

Home address:

Telephone

Second Alternate Trustee

Full Name

Relationship

Home address:

Telephone

Directive To Physicians

This document is designed to help you communicate your wishes about medical treatment at some time in the future when you are unable to make your wishes known because of illness or injury.

Below are two questions, please check your treatment preference:

If, in the judgment of your physican, you are suffering with a terminal condition from which you are expected to die within six months, even with available life-sustaining treatment provided in accordance with prevailing standards of medical care:

You request that all treatment other than those needed to keep you comfortable be discontinued or withheld and your physician allow you to die as gently as possible;
You request that you be kept be alive in this terminal condition using available life-sustaining treatment. (THIS REQUEST DOES NOT APPLY TO HOSPICE CARE.)

If, in the judgment of your physican, you are suffering with an irreversible condition so that you cannot care for yourself or make decisions for yourself and are expected to die without life-sustaining treatment provided in accordance with prevailing standards of care:

You request that all treatments other than those needed to keep you comfortable by discontinued or withheld and your physician allow you to die as gently as possible;
You request that you be kept alive in this irreversible condition using available life-sustaining treatment. (THIS REQUEST DOES NOT APPLY TO HOSPICE CARE.)

Additional requests: (any type of treatment you wish to use or not use in specific circumstances)

Statutory Durable Power Of Attorney

This document authorizes your agent to act with full power to do any and every act and exercise any and every power that you might or could do or exercise through any other person.

Full Name

Relationship

Home address:

Telephone

Back Up

Full Name

Relationship

Home address:

Telephone

Concluding Question

What would you like to discuss at your appointment:

Medical Power Of Attorney

This document authorizes your agent to make health care decisions for you in the event that you are unable to make them.

Full Name

Relationship

Home address:

Telephone

First Alternate Agent

Full Name

Relationship

Home address:

Telephone

Second Alternate Agent

Full Name

Relationship

Home address:

Telephone

Limitations on the decision-making authority of my agent are as follows: