CANLAW Information Form
To ensure we can serve your specific needs, please review the form below, fill it out, and send it to us.

Our goal is to help as many patients and survivors as possible.  Unfortunately, we have restrictions that will prevent us from helping persons in certain situations.  The following information will help up determine whether we can help you.


Please note: At your will interview, you will need to have the name, address, and telephone number of the person(s) who you want to appoint as your power of attorney, so please make sure you have that information available on the day of the clinic.

Sign in to Google to save your progress. Learn more
Name
Cancer Diagnosis
Address
Telephone
Email Address
Spouse's Name
Spouse's Telephone
Spouse's Email Address
Estimated Value of your estate (real estate, including: residence, rental property, land, vacation homes, etc.; oil & gas interest; 401(k), pension plan, annuities, IRAs; Cash/Savings; household furnishings/personal effects/motor vehicles; life insurance; business or partnership interests; Other (describe))
Estimated total debts & mortgages owed:
Are you a member, shareholder, owner or sole proprietor of any business? If yes, please explain.
Do you own property outside of Texas or property acquired before your marriage?  If yes, please explain.
Do you have a premarital agreement or post-marital agreement that affects your estate planning needs (i.e., a pre-nup agreement or divorce agreement)?
Clear selection
Are you the creator or beneficiary of any trust?  If yes, please explain.
How many children do you have?
1st Child's name
1st Child's date of birth
MM
/
DD
/
YYYY
Name of 1st Child's other parent, if different from current spouse.
2nd Child's name
2nd Child's date of birth
MM
/
DD
/
YYYY
Name of 2nd Child's other parent, if different from current spouse.
3rd Child's name
3rd Child's date of birth
MM
/
DD
/
YYYY
Name of 3rd Child's other parent, if different from current spouse.
Do you have any children or grandchildren with special needs or financial difficulty?  Please explain.
Is there anything else you think we should know?
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms