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• Your Name as you wish it to appear in your will:

_______________________________________________________________________
 

• Your Social Security number (for durable power of attorney)

_______________________________________________________________________
 
 

• Your Phone number at work: _________________

• Your Phone number at home: _________________

• Your Mailing Address (including City, State and Zip Code).

_______________________________________________________________________
 

_______________________________________________________________________
 

• Circle or enter the city or county of your Legal Residence in Virginia (not necessarily your mailing address):

Other: ____________________________________

• Are you married?  _____________

• If married, Spouse's name as you wish it to appear in your will:

_______________________________________________________________________
 

• Spouse's Social Security number (for durable power of attorney):

_______________________________________________________________________
 
 

• Spouse's Phone number at work: _________________

• Spouse's Phone number at home: _________________

List all children. It is important that all of your children be listed, whether they are (i) biological or adopted children, (ii) children of a present marriage, a prior marriage, or born out of wedlock, and (iii) even though they may have been adopted by someone else.

Please list children in date of birth order, eldest first, with date of birth:

1.  _______________________________________________________________________

2.  _______________________________________________________________________

3.  _______________________________________________________________________

4.  _______________________________________________________________________

5.  _______________________________________________________________________

6.  _______________________________________________________________________

7.  _______________________________________________________________________

8.  _______________________________________________________________________

9.  _______________________________________________________________________

10.  _______________________________________________________________________
 

• Are any of your children receiving Social Security Disability or SSI benefits?  (If yes, click here for link to Mr. Majette's monograph on Medicaid in the context of trusts and estates.)

• If so, which children are receiving these benefits and for approximately how long?

 
• _____________________________________________________
• _____________________________________________________
• _____________________________________________________

    Who would you like to serve as your primary agent?

1.  _______________________________________________________________________

    What is his or her relationship to you (son, daughter, friend, etc.)?  _____________________

    What is his or her street address? _____________________________________________

    What is his or her legal jurisdiction (e.g., City of Richmond, County of Henrico)? _____________________

    What is his or her mailing address for the City and State and Zip?

            City: _____________________________

            State: ____________________________

            Zip: ____________ _________________
 

    Who would you like to serve as your secondary agent?

2.  _______________________________________________________________________

    What is his or her relationship to you (son, daughter, friend, etc.)?  _____________________

    What is his or her street address? _____________________________________________

    What is his or her legal jurisdiction (e.g., City of Richmond, County of Henrico)? _____________________

    What is his or her mailing address for the City and State and Zip?

            City: _____________________________

            State: ____________________________

            Zip: ____________ _________________

3.    Please circle A or B, below:

    (A) Do you wish your selections to serve as primary / secondary agents, so that the secondary agent cannot serve unless the primary agent does not / cannot serve, or

    (B) Do you wish both your selections to serve at the same time?

4.    Do you wish your power of attorney to be effective immediately, or do you wish it to be held in escrow (which means that a third party you select, other than your selections for agents, will hold the power of attorney until you are unable to conduct your affairs)?

    (A) Immediate.  I want my selections to be able to serve now.

    (B). Escrow.  I want a third party to hold the power of attorney.

        The name of the third party is: _____________________________________.

        The third party's address is:     _____________________________________
                                                      _____________________________________

• Are you receiving Social Security Disability or SSI payments?

• Is your spouse receiving Social Security Disability or SSI payments?

• Are you a resident in a Virginia nursing home?

• Is your spouse a resident in a Virginia nursing home?

• Do you or your spouse receive Medicaid?

• Are you or your spouse covered by a long term care insurance policy to pay the cost of nursing home care or home health care (nursing care in the home)?

• Do you own any real estate or personal property located outside Virginia?

• If you are married, have you, during this marriage, lived in Arizona, California, Idaho, Louisiana, New Mexico, Nevada, Texas, Washington, or Wisconsin?

• Do you understand that a will can be changed or revoked at any time unless it has been written pursuant to a contract that prohibits such action?

• Have you read the pamphlet, "Why You Need A Will," by Rodney Johnson?

 
• Circle the approximate size of the estate (including insurance):

1. ILY - Other Stirpes - Capita AD = In - Out IL = In - Out

2. TST = Fm - Sp Dist Age ____ TA = Wv - No SB = Wv - No

3. NRF = In - Out TPL = Yes - No WO = Std - No NP = OK - ?

4. IBD = OK - ? WC = Yes - No OD = Yes - No LW = Yes - No

5. Exr (S) (S/E) S/S/E

6. Tee S/T

7. Gdn S/G

8. Gpa (S) S/A

9. Mpa (S) S/A

Special Instructions:

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Copyright, 2001, by R. Shawn Majette.  All rights reserved.