Name (required)

    Spouse

    Home Address

    Business Name and Address

    Spouse Business Name and Address

    Telephone

    Home

    Business

    Spouse Business

    Fax

    How long have you lived in Ohio?

    What other states have you lived in?

    Other residences (if any) you now own by type (ie. apartment, condominium, cottage, time-share, etc)

    Children and Other Dependents

    Name Relationship # of Children [num c1children]

    Name Relationship # of Children [num c2children]

    Name Relationship # of Children [num c3children]

    Name Relationship # of Children [num c4children]

    Name Relationship # of Children [num c5children]

    Name Relationship # of Children [num c6children]

    Date of Wills: Self Spouse

    Have you or your spouse created any trusts which you or your spouse has the right to amend

    which you or your spouse do not have the right to amend?

    Are you or your spouse (if applicable) the current or potential beneficiary of any will or trust?

    If the answer to any of these questions is yes, state the name of the creator of the will or trust, the relationship
    of the creator to you, the name of the trustee, and the date of the will or trust:

    Executors (must be resident of Ohio or coupled with a resident of Ohio as a Co-Executor)

    Primary:

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    For Spouse: (if applicable and different from you)

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    Trustees (this can be a corporate entity or an individual)

    Primary:

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    For Spouse: (if applicable and different from you)

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    Guardians (individuals who will have custody of your minor children)

    Primary:

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    For Spouse: (if applicable and different from you)

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    Health Care Power of Attorney

    Primary:

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    For Spouse: (if applicable and different from you)

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    Living Will (individuals who would be notified)

    Primary:

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    For Spouse: (if applicable and different from you)

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    General Power of Attorney (if other than spouse)

    Primary:

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    For Spouse: (if applicable and different from you)

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    Beneficiary Information (add additional page with beneficiary information if you have more beneficiaries)

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    Name: Relationship:

    Address: Phone:

    Specific Bequests (add additional page if you have more beneficiaries with specific bequests).

    Beneficiary: Property or Dollar Amount:

    Beneficiary: Property or Dollar Amount:

    Beneficiary: Property or Dollar Amount:

    Beneficiary: Property or Dollar Amount: