Miller Law Office, PLLC Elder Law

Registration Info

Your Details

First Name *

Middle Name *

Last Name *

Email *

Password *

Cell *

Your Contact Details

Name:

Date Of Birth *

Are you married? *

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Yes

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No

Suffix(optional)

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Jr

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Sr

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II

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III

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Other

Gender

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Male

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Female

Your Address

Full Address: *

Address Line 1 *

Address Line 2

City *

State *

County *

Zip Code *

Your Spouse Information

Your spouse's Details

First Name: *

Middle Name *

Last Name: *

Email *

Date Of Birth *

Cell *

Suffix(optional) *

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Jr

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Sr

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II

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III

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Other

Gender

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Male

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Female

State: *

Total Estate Value

What is the value of your estate? *

Revocable Trust

Trust Name *

Children and Beneficiaries

Do you have any children? *

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Yes

✓

No

Children

Select all that apply regarding your children, if any

One or more of my children are under the age of 18 years old *

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Yes

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No

My children are over the age of 18 years old *

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Yes

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No

Children Information

Child’s Full Legal Name *

Date of Birth *

Parents of Child? *

Are any of the children under 18 years old? *

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Yes

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No

How do you wish to distribute your estate to your children?

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Split shares equally

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Split shares as Follows

Percentage(%) *

Children *

Beneficiary Information

If you don’t have any descendants or your descendants do not survive you, do you wish to add a beneficiary?

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Yes

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No

Are any of your beneficiaries under 18? *

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Yes

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No

At what age would you like to have your beneficiary get full control of their inheritance in the place where stood a lump sum at the age

(for a person) If your beneficiary doesn’t survive you: Do you want their share to go to their children?

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Yes

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No

Do you want their share to be distributed to your other beneficiaries?

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Yes

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No

(For a charity) If the charity isn’t in existence at the time of your death: Do you want this share to go to a different charity?

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Yes

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No

How do you wish to distribute your estate to your beneficiaries? *

✓

Split shares equally

✓

Split shares as Follows

Percentage(%)

Spouse - Beneficiary Information

If you don’t have any descendants or your descendants do not survive you, do you wish to add a beneficiary? *

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Yes

✓

No

Beneficiary Name

Date of Birth *

Beneficiary Type *

Beneficiary Gender *

Are any of your beneficiaries under 18? *

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Yes

✓

No

At what age would you like to have your beneficiary get full control of their inheritance in the place where stood a lump sum at the age

(for a person) If your beneficiary doesn’t survive you: Do you want their share to go to their children? *

✓

Yes

✓

No

Do you want their share to be distributed to your other beneficiaries? *

✓

Yes

✓

No

(For a charity) If the charity isn’t in existence at the time of your death: Do you want this share to go to a different charity?

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Yes

✓

No

Do you want their share to be distributed to your other beneficiaries? *

✓

Yes

✓

No

How do you wish to distribute your estate to your beneficiaries? *

✓

Split shares equally

✓

Split shares as Follows

Percentage(%) *

Trustee

Provide the legal name of your trustee to administer the trust that will be created for your beneficiaries:

Primary Trustee: *

Successor Trustee: *

Financial Power of Attorney

Please name who you would like to serve as your Financial Power of Attorney, also called Durable Power of Attorney.

Primary Agent : Full Legal Name: *

Street Address: *

City: *

State: *

Zip: *

Phone Number: *

Successor Agent : *

Street Address: *

City: *

State: *

Zip: *

Phone Number: *

Financial Power of Attorney - Spouse/Partner

Primary Agent : Full Legal Name: *

Street Address: *

City: *

State: *

Zip: *

Phone Number: *

Successor Agent : *

Street Address: *

City: *

State: *

Zip: *

Phone Number: *

Medical Power of Attorney

Please name who you would like to serve as your Medical Power of Attorney.

Do you wish to use same agents as your Financial Power of Attorney? *

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Yes

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No

Primary Agent : Full Legal Name: *

Street Address: *

City: *

State *

Zip: *

Phone Number: *

Successor Agent : *

Street Address: *

City: *

State *

Zip: *

Phone Number: *

Medical Power of Attorney-Spouse/Partner

Do you wish to use the same agents as your Financial Power of Attorney? *

✓

Yes

✓

No

Primary Agent : Full Legal Name: *

Street Address: *

City: *

State: *

Zip: *

Phone Number: *

Successor Agent : *

Street Address: *

City: *

State: *

Zip: *

Phone Number: *

Summary

Your summary Details

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