Untitled Document

General Information:

Name of Spouse (11)

Will Information:

Name of Person and alternate person that you want to carry out the provisions of your Will.

Name of Independent Executor (Executrix) (12)

Name of alternate Independent Executor (Executrix) (13)

Specific Bequests. This allows certain property to be given to a particular person (beneficiary).

Do you want to make any specific bequests? (14)

If you have answered yes to the foregoing question, please fill in the below information.

Names of Beneficiaries (15)

Full Description of Property (17)

Bequests to Surviving Spouse with 30 day survival clause. If your spouse does not survive you for 30 days then the property passes as set forth under Disposition of Residue (Remainder) of Property.

Do you want to leave all your property, other than specific bequests, to your spouse? (18)

Disposition of Residue of your property.

Do you want each beneficiary to share equally in your property? (19)

Are all these beneficiaries your natural born or adoptive children? Stepchildren are not defined as your children. (20)

Are any of these beneficiaries minors (an unmarried person below the age of 18)? (21)

Names of Beneficiaries. (22)

Birth date (MM-DD-YY) (23)

Fractional share of property (25)

Trust Provisions.

If any of these beneficiaries are minors, do you want the property you are leaving them left in Trust? (26)

If you want to establish a trust for the minor beneficiaries, designate a Trustee and an Alternate Trustee.

Name of Trustee (27)

Name of Alternate Trustee (29)

Guardianship Provisions.

If you have minor children, do you want to designate a Guardian for them? This provision will only become effective if at the time of your death you are the surviving parent of your minor children. Surviving parent includes an adoptive parent, but not a stepparent. (31)

If you answered yes to the foregoing question, designate a Guardian and an Alternate Guardian.

Name of Guardian (32)

Name of Alternate Guardian (34)

Directive to Physician (Living Will) Information:

PLEASE DESIGNATE ONE OF THE FOLLOWING DIRECTIVES TO YOUR PHYSICIAN IN THE EVENT YOU HAVE A TERMINAL CONDITION FROM WHICH YOU ARE EXPECTED TO DIE WITHIN SIX MONTHS EVEN WITH LIFE-SUSTAINING TREATMENT:

I request that all treatments other than those needed to keep me comfortable be discontinued or withheld and my physician allow me to die as gently as possible. (36)

I request that I be kept alive in this terminal condition using available life-sustaining treatment. I understand that this request cannot be carried out if I am in HOSPICE care. (37)

PLEASE DESIGNATE ONE OF THE FOLLOWING DIRECTIVES TO YOUR PHYSICIAN IN THE EVENT YOU HAVE AN IRREVERSIBLE CONDITION THAT PREVENTS YOU FROM CARING FOR YOURSELF OR MAKING DECISIONS FOR YOURSELF AND YOU ARE EXPECTED TO DIE WITHOUT LIFE-SUSTAINING TREATMENT:

I request that all treatments other than those needed to keep me comfortable be discontinued or withheld and my physician allow me to die as gently as possible. (38)

I request that I be kept alive in this irreversible condition using available life-sustaining treatment. I understand that this request cannot be carried out if I am in HOSPICE care. (39)

Declaration Regarding Mental Health Treatment:

PLEASE DESIGNATE ONE OF THE FOLLOWING DIRECTIVES WITH RESPECT TO CONVULSIVE MENTAL HEALTH TREATMENT SHOULD YOU BECOME MENTALLY INCAPACITATED:

I do not consent to the administration of electroconvulsive or other convulsive treatment. (40)

I consent to the administration of electroconvulsive or other convulsive treatment. (41)

Medical Power of Attorney:

Alternate Name (45)

Durable Business Power of Attorney:

PLEASE DESIGNATE A PERSON AND ONE ALTERNATE TO ACT AS YOUR BUSINESS ATTORNEY-IN-FACT:

Alternate Name (50)

Designation of a Guardian:

Alternate Name (53)

General Information:

First Name (1)
Middle Name (2)
Last Name (3)
Date of Birth (4)
Street (5)
City (6)
State (7)
Zip Code (8)
County (9)
Phone Number (10)
Name of Spouse (11)

Will Information:
Name of Person and alternate person that you want to carry out the provisions of your Will.
Name of Independent Executor (Executrix) (12)
Name of alternate Independent Executor (Executrix) (13)
Specific Bequests. This allows certain property to be given to a particular person (beneficiary).
Do you want to make any specific bequests? (14)	Yes No
If you have answered yes to the foregoing question, please fill in the below information.
Names of Beneficiaries (15)
Relationship (16)
Full Description of Property (17)
Bequests to Surviving Spouse with 30 day survival clause. If your spouse does not survive you for 30 days then the property passes as set forth under Disposition of Residue (Remainder) of Property.

Do you want to leave all your property, other than specific bequests, to your spouse? (18)	Yes No
Disposition of Residue of your property.

Do you want each beneficiary to share equally in your property? (19)	Yes No

Are all these beneficiaries your natural born or adoptive children? Stepchildren are not defined as your children. (20)	Yes No

Are any of these beneficiaries minors (an unmarried person below the age of 18)? (21)	Yes No

Names of Beneficiaries. (22)
Birth date (MM-DD-YY) (23)
Relationship (24)
Fractional share of property (25)
Trust Provisions.

If any of these beneficiaries are minors, do you want the property you are leaving them left in Trust? (26)	Yes No

If you want to establish a trust for the minor beneficiaries, designate a Trustee and an Alternate Trustee.

Name of Trustee (27)
Address (28)
Name of Alternate Trustee (29)
Address (30)
Guardianship Provisions.
If you have minor children, do you want to designate a Guardian for them? This provision will only become effective if at the time of your death you are the surviving parent of your minor children. Surviving parent includes an adoptive parent, but not a stepparent. (31)	Yes No

If you answered yes to the foregoing question, designate a Guardian and an Alternate Guardian.

Name of Guardian (32)
Address (33)
Name of Alternate Guardian (34)
Address (35)

Directive to Physician (Living Will) Information:

PLEASE DESIGNATE ONE OF THE FOLLOWING DIRECTIVES TO YOUR PHYSICIAN IN THE EVENT YOU HAVE A TERMINAL CONDITION FROM WHICH YOU ARE EXPECTED TO DIE WITHIN SIX MONTHS EVEN WITH LIFE-SUSTAINING TREATMENT:

I request that all treatments other than those needed to keep me comfortable be discontinued or withheld and my physician allow me to die as gently as possible. (36)

I request that I be kept alive in this terminal condition using available life-sustaining treatment. I understand that this request cannot be carried out if I am in HOSPICE care. (37)

PLEASE DESIGNATE ONE OF THE FOLLOWING DIRECTIVES TO YOUR PHYSICIAN IN THE EVENT YOU HAVE AN IRREVERSIBLE CONDITION THAT PREVENTS YOU FROM CARING FOR YOURSELF OR MAKING DECISIONS FOR YOURSELF AND YOU ARE EXPECTED TO DIE WITHOUT LIFE-SUSTAINING TREATMENT:

I request that all treatments other than those needed to keep me comfortable be discontinued or withheld and my physician allow me to die as gently as possible. (38)

I request that I be kept alive in this irreversible condition using available life-sustaining treatment. I understand that this request cannot be carried out if I am in HOSPICE care. (39)

Declaration Regarding Mental Health Treatment:

PLEASE DESIGNATE ONE OF THE FOLLOWING DIRECTIVES WITH RESPECT TO CONVULSIVE MENTAL HEALTH TREATMENT SHOULD YOU BECOME MENTALLY INCAPACITATED:

I do not consent to the administration of electroconvulsive or other convulsive treatment. (40)

I consent to the administration of electroconvulsive or other convulsive treatment. (41)

Medical Power of Attorney:

PLEASE DESIGNATE A PERSON AND ONE ALTERNATIVE TO ACT AS YOUR MEDICAL ATTORNEY-IN-FACT:

Primary Name (42)
Address (43)
Phone Number (44)
Alternate Name (45)
Address (46)
Phone Number (47)

Durable Business Power of Attorney:

PLEASE DESIGNATE A PERSON AND ONE ALTERNATE TO ACT AS YOUR BUSINESS ATTORNEY-IN-FACT:

Primary Name (48)
Address (49)
Alternate Name (50)
Address (51)

Designation of a Guardian:

PLEASE DESIGNATE A PERSON AND ONE ALTERNATE AS THE GUARDIAN OF YOUR PERSON AND ESTATE:

Primary Name (52)
Alternate Name (53)

ARE THERE ANY PERSONS YOU DO NOT WANT AS THE GUARDIAN OF YOUR PERSON AND ESTATE. (54)
	Yes No

IF YOU HAVE ANSWERED YES TO THE FOREGOING QUESTION, PLEASE DESIGNATE SUCH PERSONS YOU DO NOT WANT AS THE GUARDIAN OF YOUR PERSON AND ESTATE.
Name (55)