Single Will Intake Form

Name*
First Middle Last
Other Names by which you are known:
Date of birth:
MM slash DD slash YYYY
Male or Female:
- Male
- Female
Are you a US citizen:
- Yes
- No
If no - country of citizenship:
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Home Phone*
Work Phone

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In the event of incapacitation
Who would you like to serve as your representative for making sure your health care wishes are carried out. Please list an additional alternative in case this person is unwilling or unable to serve:
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Alternate Name
First Last
Alternate Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Alternate Phone
Who would you like to serve as your representative responsible for managing your finances in the event of your incapacitation?
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Please indicate your wishes by selecting one item below:
- I want this person to be able to act on my behalf immediately.
- I want this person to be able to act on my behalf only upon certification by a doctor that I am no longer able to make decisions and act for myself
Please list an alternate for managing your finances if the first choice is unwilling or unable to serve:
Alternate Name
First Last
Alternate Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Alternate Phone

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Who would you like to serve as your personal representative / executor of this will?
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Please provide an alternate as well in case this person is unwilling or unable to serve.
Alternate Name
First Last
Alternate Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Alternate Phone
Special Provisions
Many people make special provisions for family heirlooms, jewelry, or other items of special or sentimental value to be distributed to friends or relatives. If you have such personal property and would like to leave it to a specific person, please complete the following per line above. Please note - about you indicated how you would like your assets to pass in general, please fill out this section ONLY if you desire items with specific or sentimental value to be left to a specific person. Per line please list: Item, Special Identifying features, and Recipient

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Please answer the following if you were previously married: