Confidential Power of Attorney Questionnaire

Please fill out completely and fax or mail back. This form is extremely important. Your accuracy and completeness in responding will help me best represent you. All sections and information must be filled out prior to sitting down with the attorney.

Please be sure to check all appropriate boxes. If "NONE", please state "NONE".

If "NOT APPLICABLE", please state "N/A".

PLEASE PRINT CLEARLY

1. Your Full Name:

_______________________________________________________________

First Last

2. IF MARRIED OR SEPARATED, complete (a) and (b) below:

(a) Spouses Full Name:

______________________________________________________

First Last

3. Your Street Address: ____________________________________

City ____________________ State ____ Zip Code ______________

4. Telephone Numbers:

Cell: _______________________________ ________________________

Day: ____________________/Night: ________________________

5. E-mail address: _______________________________________

6. Referred By: ___________________________________________

If referred by a person, is this a client or attorney? If you heard about the law office on the internet, which search engine? What search terms did you use?

7. Todays Date ____________________

We recommend a Durable Power of Attorney in the event of your physical

or mental disability to help you with financial affairs?

Yes ________ No ________

We recommend a Living Will telling hospitals and doctors not to prolong your life by artificial means, i.e. Terri Schiavo; Karen Quinlan?

Yes ________ No ________


How can we help you? What are your questions/other important information?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

[It is required by Court Rules that all pages be filled out in persons own handwriting prior to seeing the attorney to avoid conflicts of interest]

8. Your Sex: [ ] Male [ ] Female

9. Your Marital Status: [ ] Single [ ] Married [ ] Separated [ ] Divorced [ ] Widowed

10. Your Date of Birth: ___________________ SS # __________________

Month Day Year

11. Spouse Date of Birth: _________________ SS # __________________

Month Day Year

2. Personal representative

The person charged with administering bills, paying taxes and/or other debts, preserving, managing, and distributing assets and property is called the Personal Representative. This person should be one in whom you have trust and confidence. Your SPOUSE is usually named as primary Personal Representative r, followed by the child who lives closest to your home.

Please provide the following information about the person you wish to name to serve in this capacity.

1. PRIMARY Choice of Personal Representative:

Name: _________________________ ______________________________

First Last

Relationship: _______________ Address: ________________________

2. SECOND Choice of Personal Representative:

This individual will serve in the event that the primary executor/personal representative is not alive at the time of your death, or is unable to serve.

Name: _________________________ ______________________________

First Last

Relationship: _______________ Address: _____________________________

The two proposed of Personal Representative s must be filled out prior to meeting the attorney. We do not recommend Joint of Personal Representative s, which often cause conflicts and additional work for the Estate. It is best to select one primary person, then a secondary person.