Healthcare Directive Worksheet

HEALTHCARE DIRECTIVE WORKSHEET

FREE NO OBLIGATION INITIAL CONSULTATION

INTRODUCTION:

Information provided is held in complete confidence and is used to analyze estate planning needs and design estate planning documents.

Completing this worksheet is not mandatory prior to the initial appointment with us, but if you can complete the worksheet prior to your appointment, more information and value will be received during the complimentary initial consultation.

During the initial appointment, we will determine your specific estate planning needs and goals. The potential cost of probate and tax which would occur with your plan will be analyzed, and methods of reducing costs and accomplishing goals will be discussed. An exact quote on fees for estate planning will be provided before you authorize completion of your estate plan.

INSTRUCTIONS:

The information requested on this worksheet may seem intrusive, but we must understand your present situation and your wishes for the future. This information enables us to plan the estate to accomplish your goals, avoid probate, and save on taxes and administrative expenses.

If you (Client #1) are Married and all information on this worksheet is identical to you and your spouse (Client #2), complete only one worksheet. If information significantly differs, consider choosing the Single version of the worksheet for each person. Unmarried couples may use the worksheet as married couples, but please select the correct marital status, as it affects our recommendations for your estate planning.

Required fields are denoted by red asterisks *

Today's Date

STATUS

CLIENT #1

Marital Status: *

First Name *

Middle Initial *

Last Name *

Date of Birth *

Social Security Number

Email Address *

Check the Phone Numbers Available for Contacting You *

Mobile Phone

Work Phone

Home Phone

Mobile Phone *

Work Phone *

Home Phone *

Street Address *

City *

State *

Zip *

Client #2

CLIENT #2

First Name *

Middle Initial *

Last Name *

Date of Birth *

Social Security Number

Email Address *

Check the Phone Numbers Available for Contacting You *

Mobile Phone

Work Phone

Home Phone

Mobile Phone *

Work Phone *

Home Phone *

Client #1 *

Yes

No

Client #2 *

Yes

No

If yes, please describe briefly: *

Do you own a long-term care (nursing home) insurance policy?

Client #1 *

Yes

No

Client #2 *

Yes

No

HEALTH CARE AGENT. This individual will make medical decisions on your behalf including decisions regarding medical consents, life support issues, and nursing home admission if you cannot make these decisions yourself. Frequently, the primary agent is the spouse. It is not required to appoint the same person who is your successor trustee or personal representative as your health care agent.

Health Care Agent Name:

Health Care Agent Address:

Alternate Health Care Agent Name:

Alternate Health Care Agent Address:

Health Care Agent - Client #2

Client #2 Health Care Agent Name:

Client #2 Health Care Agent Address:

Client #2 Alternate Health Care Agent Name:

Client #2 Alternate Health Care Agent Address:

NOTES AND QUESTIONS: Please note anything else which may be important in creating your Healthcare Directive, or questions you may have.

By clicking "Submit" for the Healtcare Directive Worksheet, Client(s) represents that all information submitted has been reviewed and approved by all parties mentioned in this form.

The above statements are true and correct to the best of my knowledge.

I agree

I disagree