Your Vital Information
It is about you. We are engaged in a process to build your protective temple for you and those
you love. More important however is for you to get maximum advantage from this PROCESS. It is a
time to really understand what is important to you
To build your protective structure we must delve into your life and learn who are your
loved and trusted persons. During this process we will guide you through some of the important
issues you must address.
Our goal is to make this very personal process enlightening and beneficial. Since it is
about your values, wishes and hopes, you may choose to put down as little or as much as you
wish. Indeed feel free to skip any question that does not interest you. Make notes of questions
you may have so that we will have a meaningful consultation when we meet.
In the end you will find this to have been one of those rare life experiences that really
does make a difference to you and those you love. We are the builders, but it is your Testament
and your Legacy we are constructing.
This checklist can be intimidating. If you feel that way we find the best approach is to answer
the easy questions first and then go back for the more difficult ones.
We can best assist you if we address the very important questions:
• What keeps you up at night?
• What do you worry about for yourself?
• What do you worry about for your spouse?
• What do you worry about for your children?
• Who do you trust to take care of you if you need help?
� Are you concerned that they do not know your wishes? Your needs?
Your Legacy: in addition to helping family and friends, is there a charitable organization or
cause that you wish to remember in your Testament?
I. PERSONAL INFORMATION
YOU
Full name: When you sign legal documents do you use your full middle name or initial? No ; Initial Only ; Full Middle Name . Birth date: Home Telephone YOUR SPOUSE
Spouse: (if applicable)______________________________________

ADDRESS
Street:
City:
State:
Zip:
YOUR CHILDREN
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
YOUR SPECIAL OTHERS (partners, friends)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
PETS
Do you have a loved animal who you would like to provide for during sickness and after you
pass away?
Name_____________________________________________________________
Type of animal_____________________________________________________
Who would want to adopt your pet?_____________________________________
Special instructions__________________________________________________
__________________________________________________________________
_______________________________________________________________________
II. WILL
Your Will is central to your protective structure. For most people the Will is not the legal document for
which that they have an immediate need. It only becomes effective after we die whereas the powers of
attorney are immediately effective. However, the Will is central since it is the document that really
states who you are and what is important to you.
In the legal sense the Will does basically two things. It says who gets your property after you
die and who you trust to properly handle the "administration" of your estate. This person must fairly and
completely carry out your instructions and be responsible enough to carry out all legal duties such as
filing your final tax return.
We find that “Will contests” often reflect long buried fights between children. These surface during
probate.
– Do you have any concerns about potential disagreements/fights between children?;
– Have they always gotten along?;
– Do any have special needs that would require them to receive more help?;
– Do you feel any child needs assistance and guidance after you are gone?

We need the following information to complete your will:
FIDUCIARY CHOICES (Personal Representative formerly known as “Executor”)
Choice of PERSONAL REPRESENTATIVE (the Personal Representative is responsible for
administering the probate estate. In other states this person is called the executor.) Please be aware that
you may name as many Personal Representatives as you would like, we just ask that you list them in
order and if extra space is needed, please use the back of this page.
First Choice:
Address:
Telephone:
Relationship:
Alternate:
Address:
Telephone:
Relationship:
Are you responsible for minor children? If so you may nominate a person who will be the
Testamentary Guardian (The Testamentary Guardian is responsible for raising your children under the
age of 18 if you die and your spouse does not survive you.)
First Choice:
Second Choice:
FUNERAL PLANS
Do you wish your funeral plan to be stated in your Will? If yes, please state.
SPECIFIC BEQUESTS (Gifts)
Do you have any specific bequests for children, relatives, friends etc.?
RESIDUARY (The residue after specific gifts, if any are made)
Which persons, organizations, or charities do you want to receive the balance of your estate
(residuary) if your spouse does not survive you?

Are there any age requirements for the distribution of your residuary estate? If so, what?
________________________________________________________________________________
________________________________________________________________________________
UNEQUAL GIFTS or DISINHERITANCE
If you intend to make unequal gifts or intend to disinherit, please note your reasons:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
JOINT ACCOUNTS/JOINT PROPERTY
IF you currently have accounts OR property held with one or more other people, do you wish those
to become the property of the joint person upon your death, or do you want them distributed according
to the language of your will?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
II. DURABLE POWER OF ATTORNEY
What if you were out of town and there was some business at home that had to be taken care of? What
if you were sick for an extended period, who would take care of your affairs? Who would the bank, the
insurance company, the utilities, the tax agency talk to? How would you give that person recognized
legal authority? By a Durable Power of Attorney you give your agent (or attorney in fact) authority to
act for you.
Legal and Financial
If you were unable to carry out your financial business (for any reason - out of town visiting friends and
family or serious illness) who would you want to take care of your legal, business, personal, and
financial affairs? (List in order of priority) You may name as many Agents as you would like, we just
ask that you list them in order and if extra space is needed, please use the back of this page.
First Choice:
Address:
Telephone: Relationship:
Successor:
Address:
Telephone: Relationship:
POWERS GIVEN: A general grant of power of attorney does not include certain transactions
that families often wish to complete. Therefore, do you want to grant the following additional powers?
Yes ___ No ___ Compensation. Unless the authority to receive payment is given,
your agent may not be paid even if he or she has to lose time from
work to act as your agent.
Yes ___ No ___ Employ Family Members. Under Michigan law your agent may
employ third parties and pay them their rate but if family members
do the same work they may not be paid unless you give the
authorization.
Yes ___ No ___ Gifting. An Agent may not make a gift unless you so authorize. We
often use gifting in tax matters and nursing home Medicaid cases.
Yes ___ No ___ Self Dealing. Your Agent has the power to sell your property.
However she or he may not buy the property unless you so
authorize. For example, if you wish to move and sell some
property. Your Agent may wish to sell some of the items to your
grandchild (the Agent’s child) at a reduced rate. Your grandchild
may need a car to drive to school or furniture for a college
apartment.
FINANCIAL INSTITUTIONS/INVESTMENTS
NAME _________________________________________________________________________
ACCOUNT NO. _________________________________________________________________
NAME _________________________________________________________________________
ACCOUNT NO. _________________________________________________________________
NAME _________________________________________________________________________
ACCOUNT NO. _________________________________________________________________
INSURANCE
NAME _________________________________________________________________________
POLICY/ ACCOUNT NO. _________________________________________________________
NAME _________________________________________________________________________
POLICY/ ACCOUNT NO. _________________________________________________________
PENSION PLAN
NAME _________________________________________________________________________
POLICY/ ACCOUNT NO. _________________________________________________________

PROPERTY
LEGAL DESCRIPTION (You may attach a tax bill or assessment) ________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
PARCEL NO. __________________________________________________________________
CREDIT CARDS
NAME ________________________________________________________________________
ACCOUNT NO. _________________________________________________________________
IV(A). MEDICAL POWER OF ATTORNEY
The medical or “healthcare” power of attorney is the pillar of your protective structure that protects you
from the impersonal healthcare system. What does this document do? By this document you empower
a trusted person to guarantee you the best possible medical care according to your wishes. If you were
in the hospital and unable to make decisions for yourself, with whom would you want your doctor to
consult with about your care (that is, to be your health care advocate)? If your doctor did not explain
a medication or process such as surgery who would you trust to help you get the information you need?
A. Choice of HEALTHCARE AGENT (“PATIENT ADVOCATE”)
Under Michigan law a Patient Advocate has the authority to make all decisions and to take all
actions regarding one's care, custody and medical treatment including, but not limited to the following:
a. Having access to, obtaining copies of and authorizing release of medical and other
personal information.
b. Employing and discharging physicians, nurses, therapists, and any other health care
providers, and arranging to pay them reasonable compensation.
c. Consenting to, refusing or withdrawing any medical care; diagnostic, surgical, or
therapeutic procedure; or other treatment of any type or nature, including life-sustaining
treatments. Life sustaining treatment includes, but is not limited to breathing with the
use of a machine and receiving food, water and other liquids through tubes. These
decisions could or would allow one to die.
Please be aware that you may name as many Patient Advocates as you would like, we just ask
that you list them in order and if extra space is needed, please use the back of this page.
First Choice:

Address:
Telephone: Relationship:
Successor:
Address:
Telephone: Relationship:
IV(B). ADVANCE DIRECTIVE (“Living Will”)
We recommend an advance directive be placed in your medical power of attorney. The directive
states your instructions concerning end-of-life medical treatment. You may use the following three
choices to guide you or write your own instructions. Choice one provides for broadest authority to
terminate medical treatment. Choice two allows termination only for a coma or vegetative state. Choice
three does not allow termination of treatment regardless of your condition or prognosis. Remember,
your advocate will only make the decision if you are unable to communicate your wishes.
Please feel free to cross out or add anything you wish.
Choice 1: Life-sustaining treatment: I grant broad discretion to my Patient Advocate
I do not want life-sustaining treatment (including artificial delivery of food and water) if any
of the following medical conditions exists:
a. I am in an irreversible coma or persistent vegetative state that my doctor has reasonably
concluded that I will remain unconscious for the rest of my life.
b. I am terminally ill, and life-sustaining procedures would only serve to artificially delay
my death.
c. I have permanently lost cognitive function to the extent that I cannot communicate and
I am dependent upon life-sustaining treatment to keep me artificially alive.
d. I am conscious but have irreversible brain damage, dependent upon life-sustaining
treatment and will never regain the ability to make decisions and express my wishes.
e. I am suffering from the end stages of a degenerative condition, to the extent I cannot
swallow or breathe without mechanical assistance.
f. My medical condition is such that the burdens of treatment outweigh the expected
benefits. In making this determination, I want my Patient Advocate to consider relief of
my suffering, the expenses involved, and the quality of my life, if prolonged.
g. I *optional* further state my preference to die in my own home and do not want any
aggressive treatment plan that may only cause me to die in a hospital, prolong my
suffering, death and reliance on life-sustaining treatment. I authorize my patient
advocate in such circumstance to terminate life-sustaining treatment and remove me to
a residential setting.
h. I express my desire for hospice and authorize my patient advocate to agree to hospice
treatment, if my condition has been treated for at least 30 days. However, I waive the
foregoing 30 day limitation if the doctor certifies that I have less than 30 days to live.
I expressly authorize my Patient Advocate to make decisions to withhold or withdraw treatment
which would allow me to die, and I acknowledge such decisions could or would allow my death.
<OR>
Choice 2: Life-sustaining treatment: withhold treatment only if I am in a coma or
persistent vegetative state
I want life-sustaining treatment (including artificial delivery of food or water) unless I am in
a coma or vegetative state that my doctor reasonably believes to be irreversible. Once my doctor
has reasonably concluded that I will remain unconscious for the rest of my life, I do not want
life-sustaining treatment to be provided or continued.
I expressly authorize my Patient Advocate to make decisions to withhold or withdraw treatment
which would allow me to die, and I acknowledge such decisions could or would allow my
death.
<OR>
Choice 3: Directive for maximum treatment
I want my life to be prolonged to the greatest extent possible consistent with sound medical
practice without regard to my condition, the chances I have for recovery, or the cost of the
procedures, and I direct life-sustaining treatment to be provided in order to prolong my life.
You may add instructions on a second sheet for: 1) Care you do want 2) Care you
do not want
Mental Health Treatment Provisions
Please check Yes or No for each item.
Yes No I authorize my patient advocate to obtain all information about my mental
health treatment and I consent to the release of such information to my
patient advocate.
Yes No I authorize my patient advocate to make a petition for an Assisted Outpatient
Treatment (AOT) as an alternative to hospitalization.
Yes No I authorize my patient advocate to consent to forced inpatient hospitalization
for mental health treatment.
Yes No I authorize my patient advocate to consent to the administration of
medication for mental health treatment.
Yes No I waive my right to revoke this designation of my patient advocate for up to
thirty days a permitted by Michigan statute.
Yes No I nominate _________________ as the physician and _______________ as
the mental health practitioner who would be asked to examine me and determine whether I am able to give informed consent to mental health
treatment.
Yes No My preferences for any medication to be administered for mental health
treatment are:___________________________________________________
______________________________________________________________
I may change my mind at any time by communicating in any manner that this designation does not
reflect my wishes.
It is my intent that my family, the medical or mental health facility, and any doctors, nurses, and other
medical personnel involved in my care or mental health treatment shall have no civil or criminal
liability for honoring my wishes expressed in this designation or for implementing the decisions of my
patient advocate.
THE FIRST YEAR OF DOCUBANK IS A GIFT FROM ATTORNEY JIM SCHUSTER.
DocuBank ® Enrollment Form (part 1 of 2)
A. Member Information:
Prefix (Mr/Ms/Dr):
Name:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Email Address: DOB (Optional):
Trust Name and Creation Date: (Optional --57 character max, to appear on the face of the card.)
B. Emergency Contacts: (Optional)
The names and phone numbers of three emergency contacts and physician will be provided to hospital staff
when your directives are requested. If your living will, health care power of attorney, or other advance directive
names people to make decisions for you, please list up to three of them here in the same order. If no one is listed
in your document, please choose up to three people as emergency contacts and list them here. IF
INFORMATION IS NOT AVAILABLE NOW, YOU CAN CALL US AT 1-866-DOCUBANK with updates
any time after you receive your card.
First Emergency Contact: (Optional
Name:
Relationship:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Second Emergency Contact: (Optional)
Name:
Relationship:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Third Emergency Contact: (Optional)

Name:
Relationship:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Primary Care Physician: (Optional)
Name:
Dr. Phone:
THE FIRST YEAR OF DOCUBANK IS A GIFT FROM ATTORNEY JIM SCHUSTER.
DocuBank® Enrollment Form
E. Member Statement:
I have completed an advance directive document(s) (e.g. living will, health care power of attorney, HIPAA
authorization, other advance directive, and/or organ donation information) of my own free will and have chosen
to enroll in DocuBank® to help make my document(s) available when requested. To ensure prompt access, I
authorize that my document(s), emergency contact information, and health information stored with DocuBank®
be faxed to anyone who provides the member number and access code on my card. I will notify DocuBank®
promptly of changes in my address, emergency contact information, and health information stored by
DocuBank , and also of the revocation or replacement of my document(s). I understand that DocuBank is not ®
responsible for the validity or accuracy of any information stored by DocuBank®, including the health
information that also appears on the face of my DocuBank® card. I further understand that by accepting my card
I have verified and confirmed the accuracy of all information on the card before carrying the card. It is also my
responsibility to ensure that all the information provided remains current and accurate. I also understand that
DocuBank® does not provide legal advice, and that I may cancel this service in writing at any time by written
request to DocuBank®. A charge for destruction of documents may apply.
F. OPTIONAL INFO that can appear on the front of the DocuBank Emergency Card.
(Can be completed now or added later via www.docubank.com or by calling 866-362-8226)
Allergies: (Optional)
Please number up to 4 selections in order of importance (1-4). (Due to space constraints,
all items selected may not fit on your card.)
___ Penicillin ___ Beestings ___ Shellfish ___ ___________________
___ Sulfa ___ Latex ___ Nuts ___ ___________________
Permanent Medical Conditions: (Optional)
Please number up to 3 selections in order of importance (1-3). (Due to space constraints,
all items selected may not fit on your card.) Do not list medications you’re taking.
___ Alzheimer’s ___ Cancer survivor ___ Low vision
___ Arthritis ___ Diabetes ___ Lung disease
___ Asthma ___ Hearing loss ___ Stroke history
___ Cancer (type) ___ Heart disease ___ ____________________
_____________ ___ High blood pressure ___ __________________

Organ Donor / Anatomical Gift form is included with your directives? (Optional - circle one)
Yes No
Card Note: (Optional - 45 character max.) ___________________________________________
Attorney:
Firm name:
Membership: