You can print this off and fill out the provided fields. By bringing this packet with you to your first estate planning appointment you can assist your attorney in understanding your needs more quickly so that design can begin immediately on your plan. Simply print this page, and bring it with you.

This packet is designed to assist your attorney in creating an estate plan that will best fit your desired estate distribution. All of the information in this worksheet will help determine what documents you need, and what documents you don’t need. Typical estates will consist of a Will, Durable Power of Attorney, and Living Will. Other documents may also be needed to ensure easy transfer of assets, such as a Trust, and Beneficiary Deeds, which your attorney will discuss with you. Please complete this worksheet in as much detail as possible, reading each section carefully.

Your name(s) SSN(s)

Address City State Zip

Spouse’s Name SSN(s)

Address City State Zip

Please list those persons you wish to be beneficiaries of your estate, and identify their relationship to you:


Other than your spouse, who should be the Personal Representative (or Executor) of your estate? (This can be multiple people)

Name & Relationship:________________________________________

Other than your spouse, who should be named as a decision maker for you on a power of attorney or health care directive? In the event that you are unable to make decisions regarding your finances, and related personal needs, who should have the power to make such decisions for you? Please provide one name to act as your attorney in fact, and a back up name if possible. If you would like to have two people act as your attorney in fact at the same time, please list both and indicate such. (This can be multiple people)

Name, Address, Phone, & Relationship:____________________________________________________________

What goals or objectives do you have concerning the distribution of your assets? (Include any charitable gifts.)

Do you want your estate to become immediately available to your beneficiaries upon your death, or do you want to have your assets spread out, over a longer period?

If you own Real Estate, please tell me who you would like to receive the property, and if they are a different person from someone you already listed as a beneficiary, please indicate so and provide the same information for them as for your beneficiaries.

Real Estate (Include address, and date of acquisition):if possible please include copies of any warranty deeds/quit claim deeds/or other documents showing the transfers and legal descriptions of property ___________________________________________________________________________________________________________________________________________________________________________________________________________________


For your health care directive, also known as a Living Will, please provide the following:

Who should make your health care decisions if you are unable to make such decisions? Name a backup person if possible. *This does not have to be the same person as listed in your Durable Power, but it can be.* PLEASE LIST ONE AND A BACKUP

Name, Address, Phone, & Relationship:__________________________________________________________

Name, Address, Phone, & Relationship:___________________________________________________________

First, MI, Last If Spouse, simply write “Spouse”

Are there any specific religious needs you have for your personal health care?


The following pages include several options for your personal health care. Please read each carefully answering YES or NO for each. Keep in mind that these are designed to represent issues that may come up, but are not all issues that will come up. If you want something included that is not on this list, or are not sure about something do not hesitate to ask your attorney. You may also want to consult with your physician when making such decisions. Once you have answered, please list any additional information you wish to include or directives you wish to include in your Living Will.

LIVING WILL DIRECTIVES: Please indicate YES if you agree with the statement, and would like it included, or NO if you do not want to include the statement as written. Circle the answer you wish to apply to each.

YES NO If my physician believes that a certain life prolonging procedure or other health care treatment may provide me with comfort, relieve pain or lead to a significant recovery, I direct my physician to try the treatment for a reasonable period of time. However, if such treatment proves to be ineffective, I direct treatment be withdrawn even if so doing may shorten my life.

YES NO I direct I be given health care treatment to relieve pain or to provide comfort even if such treatment might shorten my life, suppress my appetite or my breathing, or be habit-forming.

YES NO I direct all life prolonging procedures be withheld or withdrawn when there is no hope of significant recovery and I have: a terminal condition; a condition, disease or injury without reasonable expectation that I will regain an acceptable quality of life; or substantial brain damage or brain disease which cannot be significantly reversed.

YES NO When any of the above conditions exist, I DO NOT WANT any of the following life prolonging procedures: surgery; heart-lung respiration (CPR);antibiotics; dialysis; mechanical ventilator (respirator); or tube feedings (nutrition or hydration delivered through a tube in the vein, nose or stomach).

YES NO I give the power for my representative to: Consent, refuse or withdraw consent to any care, treatment, service or procedure, (including artificially supplied nutrition and/or hydration/tube feeding) used to maintain, diagnose or treat a physical or mental condition;

Please list any special requests, wishes or directions you want to provide in your personal health care directive not included above such as specific religious desires, or any desire regarding scientific study or research, or organ donation:


Please provide a detailed list of your assets. Estate distribution can be made easier with a Trust for some, a decision that is best made when all assets are known and listed.

A. REAL ESTATE: List interest in real estate including leaseholds. Include address, name of mortgagor(s). If listed above already, please simply indicate you have done so.

Real Estate Fair Market Value Amount Owed Equity

B. MOTOR VEHICLES: List all automobiles, boats, trailers, aircraft, recreational vehicles and campers. List year, make, model.

Motor Vehicle Fair Market Value Amount Owed Equity

C. BANK ACCOUNTS: List all checking, saving and money market accounts, time deposits, certificates of deposit, money market certificates, etc. held in your name alone or with another person. Give the name of the institution, the names on the

account, the account number and the current balance.

Bank Accounts Acct No.

D. CASH ON HAND* This is for large sums kept in places other than a bank*

Cash on Hand (Money kept for saving, not in a bank)

E. SECURITIES: List all stocks, including both public and closely held corporations, bonds, promissory notes, mortgages, money market funds, and all other such property in which you have an interest. List the names in which the securities are held and the identification number, if any.

Securities (Include account numbers where applicable)

F. LIFE INSURANCE: List the type of policy, name of issuing company, policy number, insured, beneficiaries, face value and cash value (including policies from employment).

Life Insurance Beneficiary

G. HOUSEHOLD GOODS & PERSONAL GOODS: Please give the value of your household goods by category (furniture, appliances, etc). If you have valuable objects of art or jewelry, please list them separately. This is not for general items, but those items that would need direction for an estate distribution.

Item Fair Market Value

H. RETIREMENT, PENSION AND/OR PROFIT SHARING: List company, plan and participant’s percent vested and present total value, and specifiy the type of account (401k, IRA, etc.)

Retirement, Pension and/or profit sharing Fair Market Value

I. INTEREST IN TRUST: List any interest in a trust. Give name of the trust, name of the trustee, settlor, beneficiaries, nature of the interest you have in the trust and attach to this statement a copy of the trust instrument.

Interest in Trust

J. DEBTS OWED TO YOU: List debtor’s name, any security, date of loan and due date, if any.

Debts Owed To You Name of Debtor Security Date of Loan

K. INTEREST IN FARM EQUIPMENT, CROPS, ANIMALS: List the nature of the property and location.

Farm Equipment, Crops, Animals Fair Market Value Amount Owed Equity


Entity Owned Fair Market Value Amount Owed Equity

M. OTHER ASSETS: List all assets not already listed.

Other Assets Fair Market Value Amount Owed Equity

ADDITIONAL INFORMATION: Please use the remainder of this page to provide your attorney with any additional information you feel is important to fully understanding your objectives, goals and wishes in your estate plan. Attach more pages is necessary.


NOTE: Use of this worksheet alone does not create and attorney client relationship.

The choice of a lawyer is an important decision and should not be based solely upon advertisements.  The material contained in this website is for informational purposes only and is not provided in the course of an attorney-client relationship. This information is not intended to constitute legal advice from an attorney and does not form any attorney-client relationship.  Past results afford no guarantee as to future outcomes and each case must be judged on its own merits.