FOR OFFICE USE: Will General POA Deployment Living Will Durable POA for Health Care
Date Seen:___________Date for Will Execution:____________ Attorney:__________________
618-256-3542
Hours of Services
To accomplish your will or other legal assistance matters: Walk-In Legal Assistance: Monday 1300-1400, Wednesday & Friday 0800-0900 Notary/Powers of Attorney/Claims: 0900 - 1500 Monday, Wednesday, Friday & 1100 – 1500 Tuesday & Thursday
WILL WORKSHEET
Name (as you want it on will): __________________________________________________________ First Middle (Name or Initial) Last Address: Street Phone: Home ( City ) __________________________ Work ( State Zip ) _____________________________ Social Security Number: ________________ male female
State of Legal Residence: _______________________________
Military Status: AD Retired Spouse of AD Spouse of Retired Member Other Marital Status: Single Divorced Widowed Married [____time(s)] U.S. Citizen? Yes No Current Spouse’s Full Name: Children: List your children’s full names below and circle (N) natural-born, (A) adopted, or (S) stepchild: 1.______________________________________________ 2.______________________________________________ 3.______________________________________________ 4.______________________________________________ Age ____ Age ____ Age ____ Age ____ N N N N A A A A S S S S Gender ____ Gender ____ Gender ____ Gender ____ Yes No Yes No
Do you wish to treat adopted/stepchildren the same as natural-born children? Is the estimated value of your estate over $1,500,000 (incl. life insurance, investments, etc.?) Real Estate: I have no real estate. I want my real estate to pass with my residuary estate (i.e., with everything else). I would like specific individuals to inherit my real estate (enter their names below). Real Estate Recipients (if not applicable, continue on next page) Beneficiary ________________________________________ Address of the Real Estate you want this beneficiary to inherit: __________________________________________________ Beneficiary ________________________________________ Address of the Real Estate you want this beneficiary to inherit: __________________________________________________
PRIVACY ACT INFORMATION THIS INFORMATION IS SUBJECT TO THE PRIVACY ACT OF 1974
Relationship ______________
Relationship ______________
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Personal Property:
I want my personal property to pass with my residuary estate (i.e., with everything else). I give my personal property to my spouse, then my children equally. (Choose this option only if the rest of your property will go to someone else). I wish to give specific belongings to specific people: (enter their names below)
Beneficiary ________________________________________ Items _____________________________________________ Beneficiary ________________________________________ Items _____________________________________________
Relationship _____________
Relationship _____________
Residuary Estate: Your residuary estate is the remainder of your estate that you have not specifically disposed of above (normally stocks, bonds, bank accounts, etc.). To spouse only (no children). To spouse, then to my children or grandchildren equally, per stirpes. (Your spouse is deceased and you have two children,
“Sally” and “John.” If John dies before you, John’s children will get his share.)
To spouse, then to my surviving children, per capita. (Your spouse is deceased and you have two children, “Sally” and “John.” If
John dies before you, Sally will get her share and John’s share, and John’s children get nothing.)
Other (describe relationship and percent share for each beneficiary): Beneficiary__________________________________________ Beneficiary__________________________________________ Relationship_______________ Percent/Share______________ Relationship_______________ Percent/Share______________
Alternate Beneficiaries: In the event your spouse, your children, and/or any other beneficiaries above do not survive you, would you like to name alternate beneficiaries of your estate? I do not wish to name alternate beneficiaries. I would like the following individual(s) to be my alternate beneficiaries: Beneficiary__________________________________________ Beneficiary__________________________________________ Relationship_______________ Percent/Share______________ Relationship_______________ Percent/Share______________ Yes No
Cash Gifts. Would you like to make any cash gifts (i.e. a charity, church, relative)? Beneficiary__________________________________________ Beneficiary__________________________________________
Amount __________________ Amount __________________
PRIVACY ACT INFORMATION THIS INFORMATION IS SUBJECT TO THE PRIVACY ACT OF 1974
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Executor/Executrix. An executor oversees your estate (e.g., settles your debts, closes your accounts, ensures your beneficiaries receive their inheritance). Who would you like to be your Executor/Executrix? Primary ___________________________________________ Alternate __________________________________________ Relationship ______________ Relationship ______________
Guardian of Minor Children: If your spouse (or former spouse) predeceases you, who would you like to be the Guardian of your minor children? (You do not have to choose a co-primary or co-alternate). Primary____________________________________________ Relationship ______________
Co-Primary?________________________________________ Alternate___________________________________________ Co-alternate?________________________________________
Relationship ______________ Relationship ______________ Relationship ______________
Note: Guardianship can be split such that one person is the guardian of the property of the children and another person is the guardian of the person of the children. Is this an option you would like to discuss with the attorney? Yes No Minor Child Beneficiary: At what age are minors to inherit? 18 19 21 _______ (over 21 requires a trust) If you have a child who is a minor, do you want their share of your estate to be: Paid to the child’s guardian, at the election of the executor. (this is the default option) Held by executor in trust. (NOTE: a trust is not necessary if estate will pass to child at or before age 21). Held in trust by a trustee. If you have more than one child, do you want a single trust or separate trusts? Who would you like to appoint as Trustee? Trustee ___________________________________________ Relationship ______________
Alternate _________________________________________ Is your minor’s estate to pass: per stirpes per capita
Relationship ______________
Disinherited Persons. Do you have someone you wish to disinherit from your will? It is important to note that in most states, a disinherited spouse will still be allowed to inherit a share of the estate (“Spouses Share”) despite the disinheritance clause. 1. ___________________________________________ 2. ___________________________________________ Relationship ______________ Relationship ______________
PRIVACY ACT INFORMATION THIS INFORMATION IS SUBJECT TO THE PRIVACY ACT OF 1974
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Burial Requests: Do you have a specific burial request you would like entered into your will? Cremation... . . . . . with full military honors? Yes No (active duty/ retirees only) Is there a specific place you wish your ashes to be spread?___________________________________. Regular Burial. . . .with full military honors? Yes No (active duty/ retirees only) Is there a specific place you wish to be buried?____________________________________________. I want to donate my body to medicine or science. If you desire a Living Will or Durable POA, please complete the following: Living Will- instructs your physician to withhold or withdraw life-sustaining procedures if you become terminally ill, or are in a coma, or are in a persistent vegetative state with no reasonable likelihood of recovery. A living will is beneficial because it allows you to make that decision ahead of time and prevents your family from ever having to make that painful decision. Do you wish to die at home if there is nothing further that can medically be done for you? Yes No Health Care Power of Attorney- you name another person (your agent) to make medical decisions for you if you should become unable to make medical decisions yourself. The power of attorney would only become effective upon your incapacitation. Until that point, you would still be able to make your own medical decisions. Primary____________________________________________ Address____________________________________________ Alternate___________________________________________ Address____________________________________________
Phone #: ________________
Phone #: ________________
Do you wish to be an organ donor? (Check all that apply) No Yes, for transplants Yes, for scientific research Special Instructions/Limitations:_______________________________________________________ Would you like this agent to also determine the disposition of your remains? Yes No I want a Durable POA for finances (a general POA) in the event I am disabled. I want the same agents who will make my healthcare decisions to manage my finances. Yes No Agents(s)/ Attorney(s)-in-Fact: Primary____________________________________________ Address____________________________________________ Alternate___________________________________________ Address____________________________________________ Additional Information/Questions for Attorney: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Phone #: ________________
Phone #: ________________
PRIVACY ACT INFORMATION THIS INFORMATION IS SUBJECT TO THE PRIVACY ACT OF 1974
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