Legacy Planning Intake | AIDS Legal Referral Panel (ALRP)

We look forward to helping you complete your legacy documents. This intake form will provide the information we need to complete your Will, Advance Healthcare Directive, and/or Power of Attorney. To preview the full set of questions, click here.

Basic Information

Name(Required)

First Last

Date of Birth(Required)

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Which documents are you seeking support with?(Required)

Please select all documents you would like to complete. On the next pages of this form, we will ask for the information needed to complete each document you select.

Advance Healthcare Directive

Power of Attorney

Will

Demographic Information

This information is optional and will help us report to our funders. Demographic information will not determine eligibility for participation in the legacy planning clinic, but may affect eligibility for additional legal services beyond the scope of this event.

Gender

Do you identify as transgender?

Sexual Orientation

HIV Status

Race / Ethnicity (check all that apply)

American Indian or Alaskan Native

Asian or Asian American

Black or African American

Latina/o/e

Native Hawaiian or Pacific Islander

White

Other

Prefer not to say

Cultural Identity

Living situation

Household size

Veteran status

Employment status

Income range (annual)

Advance Healthcare Directive

An Advanced Healthcare Directive allows a person (principal) to state instructions regarding health care decisions should they be unable to speak, write, or sign to their health professional what they want. The principal can also elect to name another person to be their agent for health care decisions.

Agent (person with the authority to make decisions for you)

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

First Alternative (if applicable)

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Second Alternative (if applicable)

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Wishes

Do you want artificial nutrition?

Yes

No

Do you want artificial hydration?

Yes

No

Do you want pain relief?

Yes

No

Do you want to donate organs, tissue, or body parts?

Yes

No

Do you want Agent’s authority to be effective immediately?

Yes

No

Please provide any additional details/limitations regarding your responses above:

Choice to Prolong Life

Choice not to prolong life if (1) you have an incurable and irreversible condition that will result in your death within a relatively short time, (2) you become unconscious and, to a reasonable degree of medical certainty, you will not regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits.

Choice to prolong life as long as possible within the limits of generally accepted health care standards

Other

Primary Physician (Optional)

Name

First Last

Phone

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Second Physician (Optional)

Name

First Last

Phone

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Timing

Will this become effective immediately or only upon incapacitation?

Immediately

Upon incapacitation

Do you have any other questions or information to share about your Advance Healthcare Directive?

Power of Attorney

A Power of Attorney is a a document that allows the principal (the person making the document) to appoint someone they trust to act on their behalf in financial and legal matters.

Agent (person with authority to act on your behalf)

Name(Required)

First Last

Phone(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Second Agent (if applicable)

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

If you have elected to name a second agent, do you want your agents to act:

Together (like a team)

Separately (if your primary agent is unable to act, then your secondary agent steps in)

Any limiting instructions to what your agent can do on your behalf?

Will this become effective immediately or only upon incapacitation?

Immediately

Upon incapacitation

Do you have any other questions or information to share about your Power of Attorney?

Will (page 1/4)

A will is a legal document that allows a person (the testator) to outline how their property is to be distributed after their death. A will also allows the testator to appoint a person (an executor) to distribute their assets and gifts, and manage the estate.

Personal Information

Full name as it will appear on documents:

First Middle Last Suffix

Home Phone

Work Phone

Marital Status

Single

Married

Divorced

Spouse or Domestic Partner Name

First Last

Date Married

State Where Married

State / Province / Region

Date Divorced

State Where Divorced

State / Province / Region

Living Relatives

Please provide name and address (city, state) information for any living relatives. Use the (+) button to add additional lines.

Living Children

Name

City

State

Living Parents

Name

City

State

Living Siblings

Name

City

State

Deceased Relatives

Please names of any deceased children, parents, or siblings. Use the (+) button to add additional lines.

Deceased Children - Name

Deceased Parents - Name

Deceased Siblings - Name

Unknown if Living Relatives

Please names of any children, parents, or siblings who are unknown if living or deceased. Use the (+) button to add additional lines.

Unknown if Living Children - Name

Unknown if Living Parents - Name

Unknown if Living Siblings - Name

Will (page 2/4)

A will is a legal document that allows a person (the testator) to outline how their property is to be distributed after their death. A will also allows the testator to appoint a person (an executor) to distribute their assets and gifts, and manage the estate.

Will Information

Have you previously completed a will?

Yes

No

If yes, when?

Who was it prepared by?

First Last

A. Do you want to leave all of your belongings (financial assets, and tangible personal property) to one person or organization/charity?

If NO, please go to Section B.

Name

First Last

Address

City State / Province / Region

B. Do you want to leave items to specific people?

If you want to leave specific gifts to specific people, please note below how you would like to distribute your belongings (for example: I give my niece Jill $1000, I give my cousin Jeff my watch collection, etc.)

Specific Gifts

Use the (+) button to add additional lines.

Name

City

State

Description of item(s)

Who will be receiving the residue of your estate?

The residue is what remains after your specific gifts have been given, and all of your expenses have been paid. You can leave the residue to another person, or to an organization or charity.

First

Last

City

State

Executor

Person who will carry out the will.

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Alternate Executor (optional)

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you have any questions or other information to share about your beneficiaries or executor/alternate?

Do you anticipate anybody objecting to the content of your will?

Yes

No

If yes, please explain:

Will (page 3/4)

A will is a legal document that allows a person (the testator) to outline how their property is to be distributed after their death. A will also allows the testator to appoint a person (an executor) to distribute their assets and gifts, and manage the estate.

Post-Death Instructions

Burial?

Yes

No

Cremation?

Yes

No

Where?

City State / Province / Region

Memorial service or funeral details:

Who will make arrangements?

Executor

Other

If other, please provide contact information:

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Have you pre-arranged any post-death services? If so, please describe:

Do you have any other questions or information regarding post-death instructions?

Will (page 4/4)

A will is a legal document that allows a person (the testator) to outline how their property is to be distributed after their death. A will also allows the testator to appoint a person (an executor) to distribute their assets and gifts, and manage the estate.

Assets

Please provide information on your assets.

Is the total value of the estate (property, financial accounts) more than $208,000?

Yes

No

Real Property (do you own a house or land)?

If yes, how held? In your name alone, or jointly with someone else?

Life insurance information (beneficiaries, amounts, etc.)

Vehicles

Bank accounts

Trust

Retirement accounts (401(k), IRA, etc.)

Stocks, bonds, etc.

Other

Do you have any additional questions or information to share regarding your Will?

Scheduling

Please select a one-hour timeslot to meet with an attorney and finalize your documents on September 27 at Openhouse (75 Laguna Street, San Francisco). We will be in touch to confirm your appointment prior to the event!

Select a time

Thank you for completing this intake form! Do you have any final questions we can address or information to share?

Legacy Planning Intake Form

Basic Information

Demographic Information

Advance Healthcare Directive

Agent (person with the authority to make decisions for you)

First Alternative (if applicable)

Second Alternative (if applicable)

Wishes

Primary Physician (Optional)

Primary Second Physician (Optional)

Timing

Power of Attorney

Agent (person with authority to act on your behalf)

Second Agent (if applicable)

Will (page 1/4)

Personal Information

Living Relatives

Deceased Relatives

Unknown if Living Relatives

Will (page 2/4)

Will Information

A. Do you want to leave all of your belongings (financial assets, and tangible personal property) to one person or organization/charity?

B. Do you want to leave items to specific people?

Executor

Alternate Executor (optional)

Will (page 3/4)

Post-Death Instructions

Will (page 4/4)

Assets

Scheduling