Will Based Estate Plan
Individual
Full Legal Name
*
First Name
Last Name
Middle Name or Preferred Initial
*
Date of Birth
*
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Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Cell Phone Number
*
Please enter a valid phone number.
If widowed, would you like to include your partner's name in your documents? If so, what was their name and their date of death?
How did you hear about us? We are glad that you found us!
*
Referral
Facebook
Google
Other
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Children
Child One
First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Child Two
First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Child Three
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Child Four
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Child Five
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Is there anything that I should know about your kids? Special needs, substance abuse, other concerns?
If your children are minors, who would you like to name as their guardian in the event that both parents were unable to care for them?
Do you have any other family members that you specifically want to provide for?
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Your Estate
How your assets will be distributed at your death
Executor
An executor is the person who will settle your estate for you at your death. They will probate your will, settle your debts, and distribute the assets to the beneficiary.
Who would you like to serve as your executor?
*
Who would you like to serve as your successor (back-up) executor?
*
Back-up person 1
Who would you like to serve as your next successor (back-up) executor?
This is optional but encouraged
How would you like to see your estate distributed?
*
Are there any special bequests that you would like to include in your plan?
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Durable Power of Attorney
This is the power that will handle your financial affairs for you while you are alive if you become incapacitated.
Who would you like to name as your primary durable power of attorney?
*
First Name
Last Name
Who would you like to name as your successor agent?
*
First Name
Last Name
Next Successor Agent?
First Name
Last Name
Any concerns or questions about this?
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Health Care Documents
Healthcare Power of Attorney, HIPAA Release, Advanced Directive
Healthcare Power of Attorney
This is the person who will make medical decisions on your behalf if (and only if) you can't make them for yourself.
Who would you like to name as your Healthcare Power of Attorney?
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Who would you like to name as your successor healthcare Power of Attorney?
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Who would you like to name as your next successor healthcare Power of Attorney?
First Name
Last Name
Phone Number
Please enter a valid phone number.
Organ Donation
*
I do not wish to authorize organ donation
I authorize organ donation for transplant purposes only
I authorize organ donation for medical research only
I authorize organ donation for transplant or medical reserach
I do not want to include a preference about organ donation in my document
HIPAA Release - Who would you like your doctors to be able to discuss your medical care with? This grants access to information, not decision making.
*
Advanced Directive (sometimes called a Living Will) - If your medical condition is terminal and irreversible, your death is imminent, or you are in a persistent vegetative state
*
I do NOT wish to be kept alive via artificial nutrition, hydration, or ventilation
I DO want to be kept alive as long as possible using medical intervention
I have religious views that I would like to incorporate and discuss
Are there any particular concerns or questions about your healthcare documents?
Is there anything else that you want to address, worry about, want to include, etc? If in doubt, mention it. We'll discuss!
*
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