_WILL QUESTIONNAIRE_
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Name:	_____________________________________________
Address:	_____________________________________________
	_____________________________________________
Telephone:	Home _________________ Work _________________
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ESTATE WILL BE LEFT TO:
Select one only
	Spouse
	Children (Outright) (Distribution by law at age 18)
	Children (in trust)
	(Payments for support, maintenance, education)
	(Distribution at age (s) __________ )
	Parent (s)
	Brother (s) and / or Sister (s) (divided equally)
	Other : _______________________________________
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IF INDIVIDUAL (S) SELECTED ABOVE DO NOT SURVIVE ME, MY ESTATE WILL BE LEFT TO (Select one only):
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	Spouse
	Children (Outright) (Distribution by law at age 18)
	Children (in trust)
	(Payments for support, maintenance, education)
	(Distribution at age (s) __________ )
	Parent (s)
	Brother (s) and / or Sister (s) (divided equally)
	Other : _______________________________________
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IF INDIVIDUAL (S) SELECTED ABOVE DO NOT SURVIVE ME, MY ESTATE WILL BE LEFT TO (Select one only):
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	Spouse
	Children (outright)
	Children (in trust)
	Parent (s)
	Brother (s) and / or Sister (s)
	Other : _______________________________________
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FILL IN THE APPROPRIATE INFORMATION BELOW FOR THE BENEFICIARIES SELECTED ABOVE:
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Name of Spouse __________________________________ . Name of Children __________________________________ __________________________________ __________________________________ __________________________________ . Name of Parent (s) __________________________________ __________________________________ . Name of Brother (s) __________________________________ and / or Sister (s) __________________________________ __________________________________ __________________________________ . Name of Others __________________________________ __________________________________ __________________________________ . Name of Guardian of minor Children __________________________________ . Name of Alternate Guardian of Children __________________________________ . Name of (co) Trustee (s) __________________________________ ( only if Trust desired __________________________________ for Children) __________________________________ . Name of Alternate __________________________________ (co) Trustee (s) __________________________________ ( only if Trust desired __________________________________ for Children) __________________________________ . Name of Personal Representative * __________________________________ .
Are you a citizen of the United States? Yes No Is your spouse a citizen of the United States? Yes No Not Applicable . Do any of the potential beneficiaries have a physical or mental handicap? Yes No
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Approximate net worth: _______ (Including life insurance death benefit)
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NOTE
	Please Provide Full Legal Names
*	A personal representative is responsible for carrying out the provisions of your will and settling your estate. We suggest that married individuals select their surviving spouse as the primary personal representative.
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	SUPPORTING DOCUMENTS
	Advance directive:(For health care decisions)
Primary decision maker ________________________________
Backup decision maker ________________________________
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	Durable power of attorney:
Primary decision maker ________________________________
Backup decision maker ________________________________
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