Will Intake Form – Fill Out and Use This PDF

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:___________________

_______________________________________________________

***If you are not married, please list the names and address of the persons or charitable organizations that you want to receive your assets upon your death:

_____________________________________________________

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_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

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 your children are minors (under 18 years), then please state the name and address of the individual(s) you would like to recommend for guardianship [i.e.; to care for your children and their inheritance]:______________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

****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 _____; or 25 years_______

***If one of your children or beneficiary (ies) 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 (i.e.; children/grandchildren of that deceased child) [Yes _____; No ______].

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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:

Item & Full Name of Person: __________________________________

Item & Full Name of Person: __________________________________

Item & Full Name of Person: __________________________________

Item & Full Name of Person: __________________________________

Item & Full Name of Person: __________________________________

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:

_______________________________________________________

_______________________________________________________

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