Confidential Questionnaire

Confidential Questionnaire

Complete all blanks (please print)
Your full name:	____________________	D.O.B.	___/___/___
Spouse's full name	____________________	D.O.B.	___/___/___
Residential address:	____________________ ____________________	Phone: County:	( ) ___ - _______ ______________
Referred by:	____________________	May we mention this referral to the referral source? Yes __ No __
Prior marriages:	You Spouse	Yes ___ No ___ Yes ___ No ___
Children:	Please indicate if any child is by a prior marriage of yours (PM) or a prior marriage of your spouse's (SPM)
1.	____________________	D.O.B.	___/___/___
2.	____________________	D.O.B.	___/___/___
3.	____________________	D.O.B.	___/___/___
4.	____________________	D.O.B.	___/___/___
Deceased Children:	Please indicate if any child is by a prior marriage of yours (PM) or a prior marriage of your spouse's (SPM)
1.	____________________	D.O.D.	___/___/___
2.	____________________	D.O.D.	___/___/___

Which documents would you like for us to prepare?
You	Spouse
____	____	Simple Last Will and Testament (No Trust)		$150 ea*	$ ________
____	____	Simple Last Will and Testament (Trust for Children)		$225 ea*	$ ________
____	____	General Power of Attorney		$ 50 ea	$ ________
____	____	Medical Power of Attorney		$ 50 ea	$ ________
____	____	Directive to Physicians		$ 50 ea	$ ________
____	____	Organ Donation Form		$ 25 ea	$ ________
____	____	Photocopies $ 2.50 per document (____# documents per person x 2.50)			$ ________
Total Costs:					$ _______
* Any amount quoted for a Last Will and Testament does not include specific bequests. Specific bequests will increase the cost of the will by $25.00 per bequest. Also, if documents are mailed to you, there will be postage charges added.
How will you make payment?		____ By Check enclosed with this Questionnaire
Credit Card: ____ Visa ____ Master Card ____ American Express ____ Discover
Account Number: __________________________			Expiration Date: _______________
Amount I request to pay by credit card:			$ __________
Date: ___/___/___			Signature: ______________________ Print Name: _____________________
Fax or mail to: YARBROUGH & ELLIOTT, P.C. 1420 WEST MOCKINGBIRD LANE, SUITE 390, LB 115 DALLAS, TEXAS 75247 (214) 267.1100 (PHONE) (214) 267.1200 (FAX)