Simple Will Intake Form

SIMPLE WILL INTAKE FORM

for
Poklemba & Hobbs, LLC

PLEASE READ.

In a Simple Will, except for specific bequests (see below), your entire estate will either go to your spouse, or to your children, if your spouse dies before you. If you are interested in this type of a Simple Will, then please complete this form and return it to Poklemba & Hobbs, LLC. If you are not interested in this arrangement, or if you want more information, then STOP and contact Poklemba & Hobbs, LLC., at (518) 581-9797 for a private and confidential conference.

Once your Last Will and Testament is completed to your satisfaction, and you are ready to sign your Will, we will schedule a meeting at your convenience at either our Malta offices located at Visionary Park, 2715 State Route 9, Suite 102, Malta, New York 12020 or at our Glens Falls offices located at 147 Ridge Street, Glens Falls, New York 12801.

You may fill out this Simple Will Intake Form at your convenience and fax, mail or email it to our attention, and we will begin the process of completing your Simple Will quickly and conveniently for you.

PLEASE ANSWER ALL QUESTIONS

1. Personal Information:

a. Your Name

b. Your Address

c. Phone Numbers [home] [cell]

d. Marital status: Married Single

e. Your email address:

2. Spouse’s Information

a. Full Name

b. Address: Same as above or Other Address:

3. Marital Information:

a. Have you ever divorced? Yes No

4. Your Dependents (list your Children):

Name: Age:

Name: Age:

Name: Age:

Name: Age:

Name: Age:

Name: Age:

If one of your children is a minor when you die, do you want that child’s inheritance to go into a simple trust to prevent the minor child from spending the inheritance, until s/he is 18 years; 21 years; 25 years

If one of your children or beneficiary dies before you, do you want his or her share of your estate to go to your other living children? Yes No

Or do you want your deceased child’s share of your estate to go to his or her issue? Yes No

5. Specific Bequests: Do you want to make any specific bequests? (For example: my wedding ring to daughter or my gold watch to my nephew)? If so, then state:

6. Disinherit: Do you want to exclude any individuals from your will?

Yes No

If yes, then state Full Name of Each Person(s) to be disinherited:

Do you want to disinherit an individual if he or she contests your Will? Yes No

7. Executor: Who do you want to be your Executor [the person that would administer your will?] In most cases, this will be your spouse.

If Spouse check here If some other person(s), then state the full name and address of person:

Please provide name and address of Alternate Executor to be appointed in case the person that you have named Executor is unable or unwilling to perform the duties:

8. Burial Requests: Do you have any special requests for your funeral or burial?

Yes No

Specific Cemetery:

Specific Directions for Your Funeral:

Cremation: Yes No

9. Living Will/Durable Healthcare Proxy and Power of Attorney: Are you interested in a Power of Attorney, Living Will [Do Not Resuscitate Order] or Durable Healthcare Proxy [allows a person to make decisions concerning your healthcare if you cannot]?

Yes No

If yes, then please state the name, address and telephone number of the person you would like to name as your Power of Attorney (person who will make health decision on your behalf):

Please indicate name, address and telephone number of Alternate Person to Act:

10. Please mail your form to:

Poklemba & Hobbs, LLC

Attn: Gary C. Hobbs, Esq.

2715 State Route 9, Suite 102

Malta, New York 12020 – or – You may fax your form to our offices at (518) 581-9590. You may also email your completed form to phu@phulawyers.com.

When Your Last Will & Testament is ready, our office will contact you to schedule an appointment.