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.

Name
Your answer
Cancer Diagnosis
Your answer
Address
Your answer
Telephone
Your answer
Email Address
Your answer
Spouse's Name
Your answer
Spouse's Telephone
Your answer
Spouse's Email Address
Your answer
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))
Your answer
Estimated total debts & mortgages owed:
Your answer
Are you a member, shareholder, owner or sole proprietor of any business? If yes, please explain.
Your answer
Do you own property outside of Texas or property acquired before your marriage? If yes, please explain.
Your answer
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)?
Are you the creator or beneficiary of any trust? If yes, please explain.
Your answer
How many children do you have?
Your answer
1st Child's name
Your answer
1st Child's date of birth
MM
/
DD
/
YYYY
Name of 1st Child's other parent, if different from current spouse.
Your answer
2nd Child's name
Your answer
2nd Child's date of birth
MM
/
DD
/
YYYY
Name of 2nd Child's other parent, if different from current spouse.
Your answer
3rd Child's name
Your answer
3rd Child's date of birth
MM
/
DD
/
YYYY
Name of 3rd Child's other parent, if different from current spouse.
Your answer
Do you have any children or grandchildren with special needs or financial difficulty? Please explain.
Your answer
Is there anything else you think we should know?
Your answer
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