Living Will Questionnaire

Please fill out this form and submit it to our office for review.

Living Will Questionnaire

Person making Living Will: *
Best Contact Phone Number: *
Date of birth *
Email *
Do you wish to donate your bodily organs and/or bodily tissues? *
YesNo
Complete Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Names and Relationship of ANY persons that you will have discussed your wishes with: *
First Person'sName:Relationship To First Person:---------------------------------Second Person's Name:Relationship To Second Person:---------------------------------Third Person's Name:Relationship To Third Person:
RELEASE OF LIABILITY
Please read the information below and by filling in your name and the date, acts as your signature that you read and agree to the terms below.I have been informed by the Staff of Express L C L Services, Inc. d/b/a Express Non Lawyer that:(1) They ARE NOT ATTORNEYS, & they CANNOT GIVE LEGAL ADVICE. (2) They are only assisting me in the proper preparation of these documents so that I can represent myself in this matter without an attorney.They have further informed me that legal representation by an attorney would advise me of all legal rights that I may have arising out of this action.The legal documents prepared by Express L C L Services, Inc. d/b/a Express Non Lawyer,have been prepared in accordance with the information provided by me in my desire to represent myself in this transaction.I declare:(1) That the information provided by me is true and complete to the best of my knowledge and belief;(2) That I agree to review all documents prepared and my signature is acknowledgment of my approval of all documents;(3) That I hereby release Express L C L Services, Inc. d/b/a Express Non Lawyer, from any liability arising out of the services performed for me by them as the result of my failure to provide the information requested or to thoroughly review all documents. I further declare that I am signing this document without undue influence, threat or pressure from any person or entity involved in the outcome of this transaction. (4) I understand that any and all payments made to Express L C L Services, Inc. d/b/a Express Non Lawyer, for the preparation of any documents are non-refundable and that I have been informed that I must pick up my documents within 90 days of completion or the documents maybe destroyed and/or I may incur additional fees as determined applicable by the Staff of Express L C L Services, Inc. d/b/a Express Non Lawyer.
By Entering The Date & Name below, I hereby agree to the terms listed in the RELEASE OF LIABILITY.
Today's Date:My Name: By Entering The Date & My Name above, I hereby agree to the terms listed above in the RELEASE OF LIABILITY Disclaimer.
I read the terms and conditions and entered my name and date above. * *
When you submit your information to be processed, Please call our office to verify receipt of your form today, or the next business day.YesNo. If you answer NO, your form will NOT be processed.

Are You A Human?

Please enter these two digits *Example: 20
This box is for spam protection - please leave it blank:

If you would like to print off a printable form please scroll to the bottom of this page you will see our printable form.

Express NonLawyer

Phone:

(321) 729-6399

Address:

Email Us:

Business Hours:

Please note:

Living Will Questionnaire

Living Will Questionnaire

Living Will Questionnaire

Are You A Human?