Simple Will Intake Form
Personal Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Age
*
Martial Status
*
Please Select
Single
Married
Widow
Separated (Under decree of separation)
Divorced or Marriage Annulled
Spouse's Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Have you ever been divorced?
*
Please Select
Yes
No
Your Dependents
List your Children - Name & Age:
*
If none, type N/A
If you children are minors (Under 18 years), the please state the name and address of the individual(s) you would like to recommend for guardianship [i.e.; to care for your children and their inheritance]:
*
If none, type N/A
If one of your child is a minor when you die, do you want that child's inheritance to go into a simple trust to prevent the minor child from spending the inheritance, until s/he is:
*
Please Select
18 years
21 years
25 years
N/A
If none, select N/A
If one of your children or beneficiary(ies) dies before you, do you want his or her share of your estate to go to your other living children?
*
Please Select
Yes
No
N/A
If none, type N/A
or, Do you want your deceased child's share of your estate to go to his or her issue (i.e.; children/grandchildren of that deceased child)
*
Please Select
Yes
No
N/A
If none, type N/A
Back
Next
Specific Requests: Do you want any specific requests? (For example: my wedding ring to daughter or my gold watch to my nephew)? If so, then list the item and full name of person below.
*
If none, type N/A
Disinherit: Do you want to exclude any individuals from your will? Answer Yes or No. If yes, then state Full Name of Each Person(s) to be disinherited.
*
If none, type N/A
Do you want to disinherit an individual if he or she contests your Will?
*
Please Select
Yes
No
N/A
If none, select N/A
Executor: Who do you want to be your Executor [the person that would administer your will?] In most cases, this will be your spouse. If some other person(s), then state the full name and address of person:
*
If none, type N/A
Please provide name and address of Alternate Executor to be appointed in case the person that you have named Executor is unable or unwilling to perform the duties:
*
If none, type N/A
Burial Requests: Do you have any special requests for your funeral or burial? If yes, state the Cemetery and any specific directions for your funeral. If no, state N/A.
*
If none, type N/A
Cremation:
*
Please Select
Yes
No
Back
Next
Living Will/Durable Healthcare Proxy and Power of Attorney: Are you interested in a Power of Attorney, Living Will [Do Not Resuscitate Order] or Durable Healthcare Proxy [allows a person to make decisions concerning your healthcare if you cannot]?
*
Please Select
Yes
No
If yes, then please state the name, address and telephone number of the person you would like to name as your Power of Attorney (person who will make health decision on your behalf):
*
If none, type N/A
Please indicate name, address and telephone number of Alternate Person to Act:
*
If none, type N/A
Submit
Should be Empty: