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Questionnaire for Last Will and Testament, Living Will, Power of Attorney, and Health Care Power of Attorney

The purpose of this form is to provide the essential information necessary to prepare the above named documents. If you are interest in the Center preparing these documents, please type the answers below, then print and send to Roman’s attention at the Center.

FAMILY INFORMATION

1) Name Spouse’s Name

2) Are you a US citizen? Spouse

3) Your Date & Place of Birth

4) Spouse’s Date & Place of Birth

5) Your Social Security Number

6) Spouse’s Social Security Number

7) Home Address

8) Business Address

9) Home Phone Business Phone

10) Your Children (indicate if by previous marriage of you or your spouse)

Name Birth Date & SS# Address Marital Status

11) Other Dependents

12) Grandchildren:

Their Parent’s Name Name of Grandchild Birth Date SS#_

13) State the individuals whom you wish to make health care decisions in the event you are unable to make such decisions.

a) Primary Person

Name:

Relationship:

Address:

Phone Number:

b) Secondary Person (in the event the primary person is unavailable):

Name:

Relationship:

Address:

Phone Number:

14) State the individual whom you wish to make your financial decisions in the event you are unable to make such decisions.

a) Primary Person

Name:

Relationship:

Address:

Phone Number:

b) Secondary Person (in the event the primary person is unavailable):

Name:

Relationship:

Address:

Phone Number:

15) State the individual whom you wish to handle your affairs after you die.

a) Primary Person:

Name:

Relationship:

Address:

Phone Number:

b) Secondary Person (in the event the primary person is unavailable):

Name:

Relationship:

Address:

Phone Number:

16) If you have minor children, name the individual you wish to raise the children.

a) Primary Person:

Name:

Relationship:

Address:

Phone Number:

b) Secondary Person (in the event the primary person is unavailable):

Name:

Relationship:

Address:

Phone Number:

17) If you have minor children, name the individual you wish to handle the financial affairs of the children.

a) Primary Person:

Name:

Relationship:

Address:

Phone Number:

b) Secondary Person (in the event the primary person is unavailable):

Name:

Relationship:

Address:

Phone Number:

18) Questions for Living Will:

a) Do you wish to be placed on life support in the event it is necessary to keep you alive?

Spouse?

b) Do you wish to donate your organs in the event of your death? Spouse?

PRINCIPAL & ASSOCIATE

Bart Basi, CPA and Attorney at Law, is a specialist in the areas of financial analysis, taxation, business valuation, and estate and succession planning for closely-held and family businesses. He lectures, writes, researches, and advises throughout the United States.

Roman Basi, MBA and Attorney at Law, is prepared to answer all of your legal, estate planning, and tax related questions. He works with clients throughout the United States.

For more information and assistance in creating your estate plan, please contact us.

The Center for Financial, Legal and Tax Planning, Inc.

4501 W. De Young Street, Suite 200

Marion, IL 62959

Satellite Office:

Longboat Key, FL

(618) 997-3436

Fax: (618) 997-8370