INFORMATION TO WRITE A WILL, LIVING WILL, AND

DURABLE POWER OF ATTORNEY FOR HEALTH CARE

The following information is usually required to complete a will, living will, and durable power of attorney for health care. I would be happy to sit down or discuss on the phone with you the information on this sheet. If you have any questions please do not hesitate to call or schedule an appointment to discuss any of this information. Please call for a free initial telephone conversation to determine your needs.

  1. Full name of husband (including middle name) ________________________________________________
  2. Full name of wife (including middle name) ___________________________________________________
  3. Address: ______________________________________________________________________________
  4. Phone number: _____________________________e-mail: ______________________________________
  5. Name of children _______________________________________________________________________
  6. Alternative personal representative for husband _______________________________(wife is the primary personal representative if she is still alive).
  7. Alternative personal representative for wife: _________________________________ (husband is the primary personal representative if he is still alive).
  8. Guardian(s) for minor children (first and last name) ____________________________________________
  9. Guardian(s) residence (city and state) ________________________________________________________
  10. Do you want the money for the children to go into a trust or give outright to the guardians?
  11. Personal Property – are there any specific items I want to give to someone?
  12. Other Assets:
    1. Retirement accounts (who are the designated beneficiaries)
    2. Life Insurance (who are the designated beneficiaries)
    3. Home
    4. Stocks
    5. Other
  13. Living will – if I am unable to communicate my wishes and I have an incurable illness or am in a vegetative state do I want my life to be prolonged artificially with artificial life-sustaining procedures, including nutrition or hydration, or to have these medical treatments withdrawn.
  14. Durable power of attorney for health care – who will carry about my wishes expressed in the living will
    1. First Alternate Agent for husband (wife is the primary).
      1. Name: _________________________________________________
      2. Address: _______________________________________________
      3. Phone number: __________________________________________
    2. First Alternate Agent for wife (husband is the primary).
      1. Name: _________________________________________________
      2. Address: _______________________________________________
      3. Phone number: __________________________________________
  15. Power of Attorney – Agent ____________________________ Alternate __________________________


Alan R. Harrison

ALAN R. HARRISON LAW, PLLC

497 N. Capital Ave, Suite 210

Idaho Falls, Idaho 83402

Telephone: (208) 552-1165

Fax: (208) 552-1176

e-mail: arh@aharrisonlaw.com


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