CLIENT NAMES_____________________________________________________________________________

A. DISPOSITIVE INTENTIONS

1.	SPOUSE AND CHILDREN

(Husband)
Do you wish to provide primarily for your surviving spouse and secondarily for your children?  
Yes ___		No ___

Do you wish to treat all your children equally?	Yes ___		No ___

If not, why not?_______________________________________________________________________________

(Wife)
Do you wish to provide primarily for your surviving spouse and secondarily for your children?
Yes ___		No ___

Do you wish to treat all your children equally?	Yes ___		No ___

If not, why not?_______________________________________________________________________________

2.	OTHER BENEFICIARIES

(Husband)
Do you want your Will to benefit anyone other than children?	Yes ___		No ___
If so, please list the name of beneficiary and relationship:

(1) Name_____________________________________________	Relationship____________________________

Street Address________________________________________________________________________________

City_______________________________________________________ State___________ Zip_______________

Amount: $___________________________________________________________________________________

(2) Name_____________________________________________	Relationship____________________________

Street Address________________________________________________________________________________

City_______________________________________________________ State___________ Zip_______________

Amount: $___________________________________________________________________________________

 
(3) Name_____________________________________________	Relationship____________________________

Street Address________________________________________________________________________________

City_______________________________________________________ State___________ Zip_______________

Amount: $___________________________________________________________________________________

(Wife)
Do you want your Will to benefit anyone other than children?	Yes ___		No ___
If so, please list the name of beneficiary and relationship:

(1) Name_____________________________________________	Relationship____________________________

Street Address________________________________________________________________________________

City_______________________________________________________ State___________ Zip_______________

Amount: $___________________________________________________________________________________

(2) Name_____________________________________________	Relationship____________________________

Street Address________________________________________________________________________________

City_______________________________________________________ State___________ Zip_______________

Amount: $___________________________________________________________________________________

(3) Name_____________________________________________	Relationship____________________________

Street Address________________________________________________________________________________

City_______________________________________________________ State___________ Zip_______________

Amount: $___________________________________________________________________________________

B. EXECUTOR

Who do you wish to serve as your Executor?

(Husband)
First Choice__________________________________________________________________________________

Second Choice________________________________________________________________________________
 (Wife)
First Choice__________________________________________________________________________________

Second Choice________________________________________________________________________________


C. TRUSTEE

Who do you want to serve as your Trustee?

(Husband)
First Choice__________________________________________________________________________________

Second Choice________________________________________________________________________________

(Wife)
First Choice__________________________________________________________________________________

Second Choice________________________________________________________________________________

D. LIVING WILL

(Husband)
Do you want your Living Will to provide for withdrawal of artificial food and fluid?	Yes ___		No ___

Do you want your Health Care Agent to consult with any other person prior to acting?	Yes ___		No ___

If yes, with whom?____________________________________________________________________________

Name of Proposed Health Care Agent_____________________________________________________________
(usually family member or friend)

Street Address________________________________________________________________________________
(if other than child)

City_______________________________________________________ State___________ Zip_______________

Name of Proposed Alternate Health Care Agent_____________________________________________________

Street Address________________________________________________________________________________
(if other than child)

City_______________________________________________________ State___________ Zip_______________

 (Wife)
Do you want your Living Will to provide for withdrawal of artificial food and fluid?	Yes ___		No ___

Do you want your Health Care Agent to consult with any other person prior to acting?	Yes ___		No ___

If yes, with whom?____________________________________________________________________________

Name of Proposed Health Care Agent_____________________________________________________________
(usually family member or friend)

Street Address________________________________________________________________________________
(if other than child)

City_______________________________________________________ State___________ Zip_______________

Name of Proposed Alternate Health Care Agent_____________________________________________________

Street Address________________________________________________________________________________
(if other than child)

City_______________________________________________________ State___________ Zip_______________

E. POWER OF ATTORNEY

(Husband)
Name of Proposed Financial Agent_______________________________________________________________
(usually family member or friend)

Street Address________________________________________________________________________________
 (if other than child)

City_______________________________________________________ State___________ Zip_______________

Name of Proposed Alternate Financial Agent_______________________________________________________

Street Address________________________________________________________________________________
(if other than child)

City_______________________________________________________ State___________ Zip_______________

 (Wife)
Name of Proposed Financial Agent_______________________________________________________________
(usually family member or friend)

Street Address________________________________________________________________________________
 (if other than child)

City_______________________________________________________ State___________ Zip_______________

Name of Proposed Alternate Financial Agent_______________________________________________________

Street Address________________________________________________________________________________
(if other than child)

City_______________________________________________________ State___________ Zip_______________