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Estate Planning Questionnaire

If you are interested in our Estate Planning Services, please complete the form below. The information you provide will be held in strict confidence. Please read our Privacy Policy regarding information submitted on this site.

Client (full legal name):

Spouse Name:

Home Address:

City:
State:
ZIP Code:
County:
Primary Contact Number:
Primary Email:
Secondary Contact Number:
Secondary Email:

Children

Please indicate name(s) and age(s) of children:

If children are under the age of 18:

Who do you want to take care of children in case of death of both parents (include full name, address and telephone numbers)?

Name 1:
Relationship:
Address:
City:
State:
ZIP Code:
Name 2:
Relationship:
Address:
City:
State:
ZIP Code:

Executor/Executrix (A personal representative at time of death): Please indicate name, relationship and address.

Primary Name:
Relationship:
Address:
City:
State:
ZIP Code:
Alternate/Successor(s) Name:
Relationship:
Address:
City:
State:
ZIP Code:

Durable Power of Attorney

Purpose:

  • To make financial decisions on your behalf.
  • Replaces conservator or guardian being designated by court in case of incapacitation.
  • Does not have to go into effect until you become incompetent.
Primary Name:
Relationship:
Address:
City:
State:
ZIP Code:
Alternate/Successor(s) Name:
Relationship:
Address:
City:
State:
ZIP Code:
Effective Date:

If Age, what Age?

Advanced Medical Directive

Purpose:

  • Makes medical decisions on your behalf.
  • Avoids need for a guardian to be appointed by court.
Primary Name:
Relationship:
Address:
City:
State:
ZIP Code:
Alternate/Successor(s) Name:
Relationship:
Address:
City:
State:
ZIP Code:
Effective Date:

If Age, what Age?

  1. Medical Desire:

    Die Naturally

    Use life prolonging procedures:

    • Only for a reasonable length of time-if no improvements stop
    • Use only if doctor thinks it is appropriate

    All medical treatment, no matter what condition is.

    No Preference

    Other:

  2. Pain Relief when Terminal:

    Keep comfortable and as pain free as possible, even if it will shorten life.

    No medical procedures that might shorten life, regardless of pain or suffering.

  3. Post Death:

    Burial Instructions:

    Cremation Instructions:

    Ceremonial Instructions:

    Autopsy:

    • If family wants one
    • If my agent thinks it is best
    • Only if required by law

    Organ Donation:

    • Not Authorized
    • Let my agent decide
    • Anyone in need
    • Only to a blood relative
    • Restricted to only:

    Donate body to science