Print this form and fax it to: 630-990-0535
YOU:
| Full Name | |
| Date of Birth: | |
| Social Security Number: | |
| Citizenship: | |
| Home Address: | |
| Home Telephone Number: | |
| Occupation (former if retired): | |
| Office Telephone Number: | |
| Prior Marriages: | Yes NO |
YOUR SPOUSE:
| Full Name: | |
| Date of Birth: | |
| Social Security Number: | |
| Citizenship: | |
| Date of Marriage: | |
| Occupation (former if retired): | |
| Office Telephone Number: | |
| Prior Marriages: | Yes NO |
YOUR CHILDREN:
Names of Children of Present Marriage, whether natural or adopted:
List any Children of Prior Marriages (indicate Husband's or Wife's):
| A. Full Name: | |
| Date of Birth: | |
| Name of Child's Spouse (if any): | |
| Address: | |
| Grandchildren: |
| B. Full Name: | |
| Date of Birth: | |
| Name of Child's Spouse (if any): | |
| Address: | |
| Grandchildren: |
| C. Full Name: | |
| Date of Birth: | |
| Name of Child's Spouse (if any): | |
| Address: | |
| Grandchildren: |
| D. Full Name: | |
| Date of Birth: | |
| Name of Child's Spouse (if any): | |
| Address: | |
| Grandchildren: |
| E. Full Name: | |
| Date of Birth: | |
| Name of Child's Spouse (if any): | |
| Address: | |
| Grandchildren: |
| F. Full Name: | |
| Date of Birth: | |
| Name of Child's Spouse (if any): | |
| Address: | |
| Grandchildren: |
DISTRIBUTIONS:
Names and addresses of other or alternate persons to receive property:
| A. Name: | |
| Address: |
| B. Name: | |
| Address: |
| C. Name: | |
| Address: |
| D. Name: | |
| Address: |
| E. Name: | |
| Address: |
Please list any specific items or amounts that you wish to give to any individuals or organizations:
| A. Name: | |
| Gift: |
| B. Name: | |
| Gift: |
| C. Name: | |
| Gift: |
| D. Name: | |
| Gift: |
All other tangible personal property (automobiles, Clothing, furniture, pictures, etc.) to be distributed to
(check one):
| Spouse, if spouse predeceases, to children equally | |
| Children, equally | |
| Other (specify) |
WHO WILL SERVE AS YOUR PERSONAL REPRESENTATIVE?:
EXECUTORS:
| Each spouse for the other? | Yes NO |
| Someone else? | |
| Name: | |
| Address: | |
| Alternate: | |
| Address: |
TRUSTEES:
| Each spouse for the other? | Yes NO |
| Someone else? | |
| Name: | |
| Address: | |
| Alternate: | |
| Address: |
GUARDIANS: (Of minor children, if applicable):
| Name: | |
| Address: | |
| Alternate: | |
| Address: |
Any other messages: