Law Offices of
Hehr & Myers Co., L.P.A.

440-449-3266

4401 Rockside Road Ste 200
Independence, OH 44131

Estate Planning Form

Person to Contact About Submitted Information

Name:

Main Phone:

E-mail:

Client's Personal Information

Name:

St. Address:

City:

State:

Zip:

Date of Birth:

Main Phone:

E-mail:

Date of Marriage:

Spouse's Name:

Spouse's Date of Birth:

Client's Will Planning Information

Will Executor & Alternates

1. Name:

Phone:

Address:

City:

State:

Zip:

Alternates

2. Name:

Phone:

Address:

City:

State:

Zip:

3. Name:

Phone:

Address:

City:

State:

Zip:

Beneficiaries Information

1. Name:

Relationship:

Portion Received:

%

2. Name:

Relationship:

Portion Received:

%

3. Name:

Relationship:

Portion Received:

%

4. Name:

Relationship:

Portion Received:

%

Any special gifts intended:

Guardians for Minor Children

1. Name:

Relationship:

2. Name:

Relationship:

Notes:

Power of Attorney Information

Financial Power of Attorney:

Check if same as executor

Name:

Relationship:

Phone:

Address:

City:

State:

Zip:

Alternate:

Name:

Relationship:

Phone:

Address:

City:

State:

Zip:

Health Care Power of Attorney:

Check if same as executor

Name:

Relationship:

Phone:

Address:

City:

State:

Zip:

Alternate:

Name:

Relationship:

Phone:

Address:

City:

State:

Zip:

HIPAA Authorized Individuals

1. Name:

2. Name:

3. Name:

4. Name:

  


 

Hehr Myers

© 2006 Hehr & Myers Co., L.P.A., Estate and Business Planning