Will Intake Form (Page 2 of 2) in pdf

Name____________________________________________________

7. Disinherit

Do you want to exclude any individuals from your will? Yes_____ No_______. If yes,

State Full Name of Person(s)______________________________________________________

Do you want to disinherit an individual if he or she contests the will? Yes______ No________

8. Executor

Who do you want to administer your will? In most cases, this will be your spouse. If Spouse check

here______________. If other person(s), state the full name and address of person below:

______________________________________________________________________________

**Please provide name and address of Alternate Executor:

______________________________________________________________________________

9. Burial Requests

Do you have any special requests for your funeral or burial?

Specific Cemetary_______________________________________________________________

Specific Directions for Funeral______________________________________________________

Cremation Yes_______ No_________

10. Living Will/Durable Healthcare Power of Attorney for $150.00

Are you interested in a Living Will or Durable Healthcare Power of Attorney for $150.00?

Yes______ No________

If yes, then please state the name, address and telephone number of the person you would like to name as

your Power of Attorney (person who will make health decision on your

behalf)____________________________________________________________________

__________________________________________________________________________

Please indicate name, address and telephone number of Alternate Power of Attorney:

__________________________________________________________________________

PLEASE READ: Living Wills and Power of Attorney may not be available for pick-up at the Will Clinic, but

every attempt will be made to allow for this.

11. Return Your Form

Please mail your form to:

Mangano Law Offices Co., LPA

2245 Warrensville Center Road, Ste. 213

Cleveland, Ohio 44118

You may fax your form to our offices at (216) 397-5845. You may email your form to our offices at

. Please specify “WILL FORM” on subject line. Please email questions to

us at

WE RESPECT YOUR PRIVACY. If you would prefer to finalize your Will in a more private setting, please

check here_______. We will contact you to schedule an appointment.

Will Intake Form Page 2