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I. Client Information

Name:
Address Line 1
Address: Line 2
City:
State:
Zip:
Date of Birth
Email address:
Telephone Number:
Best time to call:

II. Marital Status / Spouse's Information

Your Current Marital Status:

Spouse's Full Name:

Other names used by spouse:

Spouse's age:

Spouse's date of birth:

Date of marriage:

Place of marriage:

Name of current employer:

Business phone:

Occupation:

Present state of health:

Previously executed a will:

Previously established a trust:

                    Have you entered into any pre-nuptial or post-nuptial
                    agreements? Yes   No
                                              Date:
                            State & County:

III. Children

Name:
Date of birth:

Name:
Date of birth:

Name:
Date of birth:

Name:
Date of birth:

Name:
Date of birth:

IV. Children By Previous Marriage

Name:
Date of birth:

Name:
Date of birth:

Name:
Date of birth:

Name:
Date of birth:

V. Grandchildren

Name:
Date of birth:
Mother:
Father:

Name:
Date of birth:
Mother:
Father:

Name:
Date of birth:
Mother:
Father:

Name:
Date of birth:
Mother:
Father:

VI. Siblings

Name:
Relation:

Are you or any member of your family a beneficiary of any trust established by others:

Please provide for us the legal description of any real property in which you have an interest:

Do you anticipate the amount of your combined estate (including, but not necessarily limited to real estate, personal property, insurance proceeds, investments, retirement accounts/funds, etc.) to be:

Please describe your general desires, goals, and objectives with regards to how you would like your estate to be treated/distributed upon your death. Please include any special concerns you may have.

1) Statutory Durable Power of Attorney

A Statutory Durable Power of Attorney is designed to allow the designated person or persons to manage your financial affairs should you become mentally or physically unable to do so.

A Health Care Power of Attorney allows the designated person or persons to consent to medical care on your behalf should you suffer an injury or become mentally or physically disabled.

A Designation of Guardian for Yourself allows the designated person to serve as your guardian should you become incapacitated.

A HIPAA Authorization for Release of Patient Health Information is designed to allow the designated person or persons obtain copies of your medical records.

A Directives to Physicians (also known as a "Living Will") instructs your doctor to disconnect any life support systems if you are suffering from an incurable or irreversible condition caused by injury, disease, or illness certified to be a terminal condition by two physicians.