Living Will Questionaire

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

Living Will Questionnaire (Fee $15)

Person making Living Will: *
Best Contact Phone Number: *
Your Contact Email Address *
Date of Birth *
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:, Please tell us how that person is related to you

Name of first person *
Relationship *
Name of second person
Relationship
Name of third person
Relationship
RELEASE OF LIABILITY *
Please read the information below and by clicking on EACH CHECK BOX below acts as 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:They ARE NOT ATTORNEYS, & they CANNOT GIVE LEGAL ADVICE.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:That the information provided by me is true and complete to the best of my knowledge and belief;That I agree to review all documents prepared and my signature is acknowledgment of my approval of all documents;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.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.
I hereby agree to the terms listed in the RELEASE OF LIABILITY.
Your Name: *Typing in your name here states that you read our Release of Liability and agree to the terms.
Today's Date *

Are You A Human?

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Living Will Questionaire

Living Will Questionnaire (Fee $15)

Names and Relationship of ANY persons that you will have discussed your wishes with:, Please tell us how that person is related to you

Are You A Human?