Questionnaire for Last Will and Testament

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					                           Questionnaire for Last Will and Testament
Full Name:
Street Address:
City:                                                               State:       Zip:
Home Telephone:                                       Work Telephone:
Cell Phone:                                           E-Mail:
Date of Birth:
Social Security #:                                    Marital Status:

                                      Spousal Information (if applicable)
Full Name of Spouse:
Spouse’s Date of Birth:                               Spouse’s Social Sec. #:

                                     Family Information
                    Full Names and Addresses of Children                        Birth Dates




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                                               Beneficiary Section
           YOU MAY NAME AS MANY BENEFICIARIES AS YOU WANT
If you want to leave property to one or more persons, charities or institutions, please list
them below. If you want to leave all of your property to your spouse, simply indicate “all
property to spouse” below:


                          Beneficiary Name/Address:                  Percentage or Property
‫ڤ‬


‫ڤ‬


‫ڤ‬


‫ڤ‬


‫ڤ‬


‫ڤ‬



                                               SPECIAL BEQUESTS




Alternate Beneficiaries if the above-named people predecease you:




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                                     REGARDING MINOR CHILDREN

Do you wish to appoint a guardian for your minor children: Yes ‫ ڤ‬No ‫ڤ‬
If yes, please complete the following:
Guardian Name:
Address:
City:                                               State:       Zip Code:
Telephone No.:
Alternate Guardian Name:
Address:
City:                                               State:       Zip Code:
Telephone No.:
                       PERSONAL REPRESENTATIVE OF YOUR ESTATE
Personal Representative Name:
Address:
City:                                   State:                   Zip Code:
Telephone No.:
Alternate Personal Representative Name:
Address:
City:                                   State:                   Zip Code:
Telephone No.:
Spouse Personal Representative Name:
Address:
City:                                   State:                   Zip Code:
Telephone No.:
Spouse Alternate Representative Name:
Address:
City:                                   State:                   Zip Code:
Telephone No.:
                                               BURIAL REQUESTS

Burial Service ‫ڤ‬                   Cremation ‫ڤ‬



                                     LIVING WILL QUESTIONNAIRE
Name of Agent to be Appointed:
Address:
City:                                               State:       Zip Code:
Telephone No.:




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                              LIVING WILL QUESTIONNAIRE (Cont’d.)
Alternate Agent:
Address:
City:                                                    State:              Zip Code:
Telephone No.:

Spouse Agent to be Appointed:
Address:
City:                                                    State:              Zip Code:
Telephone No.:

Alternate Spouse Agent:
Address:
City:                                                    State:              Zip Code:
Telephone No.:

                             POWER OF ATTORNEY QUESTIONNAIRE
Name of Attorney-in-Fact:
Address:
City:                                                    State:              Zip Code:
Telephone No.:

Alternate Attorney-in-Fact:
Address:
City:                                                    State:              Zip Code:
Telephone No.:

Spouse Attorney-in-Fact:
Address:
City:                                                    State:              Zip Code:
Telephone No.:

Spouse Alternate Attorney-in-Fact:
Address:
City:                                                    State:              Zip Code:
Telephone No.:

                                       EFFECTIVE DATE (Check One):

‫ ڤ‬Effective when signed                             OR     ‫ڤ‬Effective only upon disability or incapacity




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                REGARDING CHARITABLE CONTRIBUTIONS (Check One):
‫ ڤ‬My attorney-in-fact may make gifts to my spouse, children or other religious or
  educational institutions provided for under the Internal Revenue Code.
                                          OR
‫ ڤ‬My attorney-in-fact may pay pledges and make such gifts as I have regularly
  made.
                                          OR
‫ ڤ‬My attorney-in-fact may pay pledges previously made, but shall have no authority to
  make other gifts for me.
                                              COMMENTS/NOTES:




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