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About You
Name
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Dr.
Miss
Mr.
Mrs.
Ms.
Mx.
Prof.
Rev.
Prefix
First
Middle
Last
Suffix
Address
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Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Email
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Phone
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Marital Status
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Single
Married
Date of Birth
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MM slash DD slash YYYY
About Your Family
Spouse's Name
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First
Last
Do you have children?
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Yes
No
Children's Names and Birth Years
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Child's First Name
Child's Last Name
Year of Birth
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Are any of your children under the age of 18?
*
Yes
No
Guardian Nomination
*
First Name
Last Name
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If any of your children are under 18 when you pass away, they may need a guardian appointed. Who would you want to raise them through the rest of their childhood?
Gifts (both specific and everything else)
Are there specific gifts you want to leave to someone?
*
Yes
No
Specific items or dollar amounts you wish to leave someone.
*
Who are you giving this to?
Item/Amount
Relationship to You
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Please provide one gift per line (max of 10) using the format: Name, Item/Amount, Relationship
After any specific gifts have been given, who do you want to receive the remainder of your stuff?
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Name
Percentage
Relationship to You
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Please ensure that the percentage adds up to 100.
Trustees/Executors
Choose one and a backup. The Trustee is the person who administers your trust when you're either incapacitated or have passed away. The Executor is the person who will submit your will to the court (if necessary).
Primary Trustee/Executor
*
First
Last
Backup Trustee/Executor
*
First
Last
Power of Attorney Agent
Choose one and a backup. This person will be responsible for making financial decisions on your behalf when you can't.
Primary Power of Attorney Agent
*
First
Last
Backup Power of Attorney Agent
*
First
Last
Advance Medical Directive Agent
Choose one and a backup. This person will be responsible for making medical decisions on your behalf when you can't.
Primary Advance Medical Directive Agent
*
First
Last
Backup Advance Medical Directive Agent
*
First
Last
HIPAA Agents
A HIPAA Agent is someone who is permitted to get information about you and your medical treatment.
HIPAA Agents
*
First Name
Last Name
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Notes
Is there anything else we should know?
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