Request Form

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1. Print this page with the printer option on your computer.

2. Mark the box of the document(s) you wish to have drafted for you.

3. Fill in the requested information as set forth for each document.

4. Mail this form to:

Missouri Durable Power of Attorney c/o

 Michael J. Denk, Attorney at law

P.O. Box 6464

Chesterfield, Missouri 63006

5. Include a check for the appropriate amount made payable to: "Michael J. Denk"

6. Two (2) originals of your documents, including detailed signing instructions, will be promptly drafted and mailed to you.

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7. Your Information:

Name: _________________________________________________________

Address: _______________________________________________________

Telephone Number: ______________________________________________

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8. Documents Requested:

[_] Durable Power of Attorney for Personal Financial Decisions.....Cost $175.00

 ~ includes two (2) originals and detailed signing instructions

Name of Principal: ________________________________________________

Address: ________________________________________________________

Is the Principal married: ______  and if so, to whom ______________________

Does the Principal have children: ______

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Name of Initial Attorney in Fact: _____________________________________

Address: _______________________________________________________

Relationship to Principal: ____________________

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Name of 1st Successor Attorney in Fact: ______________________________

Address:________________________________________________________

Relationship to Principal: ___________________

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Name of 2nd Successor Attorney in Fact: _____________________________

Address: _______________________________________________________

Relationship to Principal: ___________________

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[_] Durable Power of Attorney for Health Care Decisions ...........Cost $175.00

 ~ includes two (2) originals and detailed signing instructions

[_] Living Will/Advanced Health Care Directive............................Cost $50.00

 ~ includes two(2) originals and detailed signing instructions

Name of Declarant: _____________________________________________

Address: ______________________________________________________

Drafting Requests: (attach a page of paper with any special drafting instructions)

Mark this box [__] if you would like your Living Will/Advanced Health Care Directive to be drafted as part of and incorporated into your Durable Power of Attorney for Health Care Decisions as one (1) document. This is strongly recommended. The total cost for both documents drafted jointly as one document is the discounted price of $200.00.

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9. Signature of Agreement:

Your Signature: ____________________________________________

Date: ____________________________________

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By signing above you agree this form will serve as the written agreement between yourself and Michael J. Denk, Attorney at Law, to draft and provide you with the documents you have requested (based upon the information you have set forth on this form) at the cost as set forth above. The signing of your documents in the presence of a notary public and two disinterested witnesses will be your responsibility. Signing instructions will be provided with your documents. You understand and agree no legal advice is being provided to you and you should consult with an Attorney of your choice for such advice. You hereby release Michael J. Denk and Missouri Estate Planning, LLC from any and all claims relating to your use of such documents. If you have any questions or concerns please contact us prior to signing and returning this form. Thank you.

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