Questionnaire

Instructions

This is a general questionnaire designed to be applicable to as many people as possible.  Some aspects of the questionnaire may not apply to your specific situation, so please ignore the section(s) not applicable to you.  There is a section at the end of the questionnaire where you may provide us with additional information relating to your particular circumstances if you choose.  You may complete this form by hand and mail or fax it to our office.  You may also complete the form online and submit it to us via email.

Your name as you’d like it to appear in your estate plan (middle name, middle initial or neither). Please keep in mind that your name as it appears in your estate plan will be the name you use to sign your documents.


Your Information

Spouse's Information (if applicable)

Spouse’s Name as he/she would like it to appear in your estate plan (middle name, middle initial or neither).


Estate Division

Briefly describe the manner in which you desire your estate be divided among your children and/or other beneficiaries. (We will discuss this area in greater detail during our initial office meeting):

State any specific gifts of money or property such as personal items, the recipients of any such gifts, your relationship to the recipient, and the amount of money or property to be given to each recipient. (We will discuss this area in greater detail during our initial office meeting):

Children of Marriage

Your Children from Prior Relationship (if applicable)

Spouse's Children from Prior Relationship (if applicable)

Disabled Children

If any of the children are disabled, list the public benefits received below. Would you like a special trust established for the benefit of the disable child?

Stepchildren, Adopted Children, or Foster Children

If any of the children are stepchildren, adopted children, or foster children, are they to be treated as children under your testamentary plan?:

Trustees, Executors, and Fiduciaries

Trustees (Administer the trust upon your death or incapacity)



Durable Power of Attorney (Agents who handle your financial affairs upon your incapacity)

Husband

Wife

Advance Health Care Directive (Agents who communicate with health care providers on your behalf upon your incapacity)

Husband

Wife

Guardians of Minor Children (if applicable)

Advance Healthcare Directive (Living Will)

Your Wishes

Do you prefer life sustaining treatment beyond the time medical doctors advise your family that there is no chance of regaining consciousness?

YesNo

Do you want your doctors to provide pain medication even if doing so might hasten your death?

YesNo

Do you want to donate your organs upon death?

YesNo

Spouse's Wishes (if applicable)

Do you prefer life sustaining treatment beyond the time medical doctors advise your family that there is no chance of regaining consciousness?

YesNo

Do you want your doctors to provide pain medication even if doing so might hasten your death?

YesNo

Do you want to donate your organs upon death?

YesNo

Additional Information

Please provide any additional information that you believe is relevant to your estate plan.