Incapacity Documents Worksheet

Thank you so much for contacting our law office. We look forward to assisting you with new incapacity documents.

Please fill out this form in its entirety, we will be in touch to schedule a phone call or video conference once received.

This intake form collects information for a single person who intends to create an Incapacity Plan (e.g. Powers of Attorney) for themselves and does not collect information for a spouse or partner. If you are a relationship and are intending to create an estate plan for you and a partner such as your spouse, please contact our office for the intake form targeted for 2 clients.

If you have any questions, please don't hesitate to contact our law office at 425-440-3494. We look forward to working with you.

PART I - Personal Information

Contact information: Client

Prefix

First name *

Middle name

Last name *

Date of birth

Emails

Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

Also Known As:

(other names used to title property and accounts)

How do you sign your Legal Name?

Are you currently employed?

Yes

Have you ever been divorced?

Yes

Are either of your parents still living?

Yes

CHILDREN

Child #1

If applicable, please fill out the following information.

Full Legal Name:

Date of Birth:

Relationship to You:

ex: Client 1's Child, Client 2's Child, Sibling, Cousin, etc.

Additional Information:

Special Needs, Concerns, Adopted, etc.

Child #2

If applicable, please fill out the following information.

Full Legal Name:

Date of Birth:

Relationship to You:

ex: Client 1's Child, Client 2's Child, Sibling, Cousin, etc.

Additional Information:

Special Needs, Concerns, Adopted, etc.

Child #3

If applicable, please fill out the following information.

Full Legal Name:

Date of Birth:

Relationship to You:

ex: Client 1's Child, Client 2's Child, Sibling, Cousin, etc.

Additional Information:

Special Needs, Concerns, Adopted, etc.

IMPORTANT PLANNING QUESTIONS

(Please check “Yes” or “No” for your answer)

Are you receiving Social Security, disability, or other governmental benefits?

Yes

Have you completed previous will, trust, power of attorney, advanced directive or estate planning?

Yes

Are you concerned with estate taxes?

Yes

Power of Attorney

If you were unable to make financial decisions for yourself, who would you want to make those decisions for you?

Agent #1:

if applicable, please select "Designate an Agent" and add the appropriate information

Designate an Agent

Not Applicable

Agent #2:

if applicable, please select "Designate an Agent" and add the appropriate information

Designate an Agent

Not Applicable

Agent #3:

if applicable, please select "Designate an Agent" and add the appropriate information

Designate an Agent

Not Applicable

Do you want to authorize your Financial Agent to make gifts on your behalf during any period of time you are incapacitated?

Yes

Living Will

Do you want to provide that the moment of your death not be unnecessarily prolonged by artificial means or measures?

Yes

Would you like to provide pregnancy provisions?

Yes

Health Care

If you were unable to make decisions for yourself, who would you want to make decisions for you with regard to your medical treatment?

Agent #1:

if applicable, please select "Designate an Agent" and add the appropriate information

Designate an Agent

Not Applicable

Agent #2:

if applicable, please select "Designate an Agent" and add the appropriate information

Designate an Agent

Not Applicable

Agent #3:

if applicable, please select "Designate an Agent" and add the appropriate information

Designate an Agent

Not Applicable

OTHER ITEMS TO INCLUDE OR DISCUSS

Obviously your estate plan should address all your hopes, fears, and wishes. Please list any other items you want included or want to discuss:

THANK YOU

When you are finished, please click the "Submit" button.