Advance Directives Questionnaire

Advance Directives Questionnaire
Full Legal Name

PrefixFirst NameMiddle NameLast NameSr., Jr., III
Date of Birth:

MonthDayYear
Date
Marital Status

SingleMarriedWidow/Widower
Address

Street Address

Street Address Line 2

CityState

Zip Code
County
Phone Number
Please enter a valid phone number.
Email
example@example.com
Send Drafts Via:

EmailMailClient pick upPortal
Date Questionnaire Completed

MonthDayYear
Date
Type of ID/State you will provide for the Notary?
ID Expiration Date:

MonthDayYear
Date
Office Location for Signing
Location where the documents will be signed:

In-Office (Witnesses and Notary provided)Out of Office (Client provides (2) witnesses and Notary)
DURABLE POWER OF ATTORNEY

Who do you want to name as agent(s) on your Durable Power of Attorney? These Agents are responsible for making Legal and Financial decisions on your behalf.

In what capacity will your Agents act?

"In Succession" only one Agent can act at a time. Should something happen to that initial Agent, only then can the following Agent(s) act.

"Must Act Jointly" all listed Agents must act together to come to a mutual decision.

"May Act Separately" all Agents can act independently from one another.
Name of Agent

PrefixFirst NameMiddle NameLast NameSr., Jr., III
Address

Street Address

Street Address Line 2

CityState

Zip Code
Relationship to Client
How would you like your respective Agents to act?

In SuccessionMust Act JointlyMay Act Separately
Name of Agent

PrefixFirst NameMiddle NameLast NameSr., Jr., III
Address

Street Address

Street Address Line 2

CityState

Zip Code
Relationship to Client
How would you like your respective Agents to act?

In SuccessionMust Act JointlyMay Act Separately
Name of Agent

PrefixFirst NameMiddle NameLast NameSr., Jr., III
Address

Street Address

Street Address Line 2

CityState

Zip Code
Relationship to Client
How would you like your respective Agents to act?

In SuccessionMust Act JointlyMay Act Separately
HEALTH CARE SURROGATE

Who do you want to name as Agent(s) on your Health Care Surrogate? These agents are responsible for making medical decisions on your behalf.

In what capacity will your Agents act?

"In Succession" only one Agent can act at a time. Should something happen to that initial Agent, only then can the following Agent(s) act.

"Must Act Jointly" all listed Agents must act together to come to a mutual decision.

"May Act Separately" all Agents can act independently from one another.
Name of Health Care Agent

PrefixFirst NameMiddle NameLast NameSr., Jr., III
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
How would you like your respective Agents to act?

In SuccessionMust Act JointlyMay Act Separately
Name of Health Care Agent

PrefixFirst NameMiddle NameLast NameSr., Jr., III
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
How would you like your respective Agents to act?

In SuccessionMust Act JointlyMay Act Separately
Name of Health Care Agent

PrefixFirst NameMiddle NameLast NameSr., Jr., III
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
How would you like your respective Agents to act?

In SuccessionMust Act JointlyMay Act Separately
PRENEED GUARDIAN

Who do you want to name as your Preneed Guardian? Please note the agents cannot act jointly as your guardian unless they are married.

This document is a proactive legal measure to ensure that someone is in place to make decisions on behalf of the individual who is or is not yet incapacitated but is at risk of becoming incapacitated in the future. This individual is appointed by a court to serve as the legal guardian.
Name

PrefixFirst NameMiddle NameLast NameSuffix
Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Is there anyone you wish to not elect as a potential Pre-need Guardian of your person and property?
Disposition of Remains

Who do you want to name as Agent(s) for your Disposition of Remains? These agents are responsible for carrying out your wishes regarding your remains.
Disposition of Remains
Burial Instructions for your agent
Name

PrefixFirst NameLast NameSuffix
Address

Street Address

Street Address Line 2

CityState

Zip Code
Telephone Number
Please enter a valid phone number.
How would you like your respective Agents to act?

In SuccessionMust Act JointlyMay Act Separately
Additional Agents
Should be Empty: