Request Form

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1. Print this page using the printer option on your computer or click on the printer icon at the bottom of this page.

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. Attach a separate page with any special drafting instructions.

5. Review the Important Notes at the bottom of this page.

6. The Principal must sign here* ______________________________

    *(by sigining the Principal acknowledges and agrees to the

       Important Notes set forth at the bottom of this page)

7. Mail this form to:

Missouri Durable Power of Attorney c/o

Michael J. Denk, Attorney at Law

P.O. Box 6464

Chesterfield, Missouri 63006

8. Include a personal check payable to "Michael J. Denk" in the amount of $195 per document requested.

9. Your Full Legal Name: _____________________________________

Your Mailing Address:________________________________________

____________________________________________________________

Your Telephone Number: ____________________________________

Your Relationship to Principal:________________________________

10. [__] Durable Power of Attorney for Personal Financial Decisions

Full Legal Name of Principal:

___________________________________________________________

Mailing Address of Principal:

___________________________________________________________

___________________________________________________________

Is the Principal married: _______      have children: _______

Full Legal Name of the Individual to Serve as the Initial

Attorney in Fact:

___________________________________________________________

Mailing Address of the Initial Attorney in Fact:

___________________________________________________________

___________________________________________________________

Relationship of the Initial Attorney in Fact to the

Principal:__________________________________________________

Full Legal Name of the Individual to Serve as the First

Successor Attorney in Fact: ___________________________________________________________

Mailing Address of the First Successor Attorney in Fact:

___________________________________________________________

___________________________________________________________

Relationship of the First Successor Attorney in Fact to the

Principal:__________________________________________________

Full Legal Name of the Individual to Serve as the Second

Successor Attorney in Fact:

__________________________________________________________

Mailing Address of the Second Successor Attorney in Fact:

__________________________________________________________

__________________________________________________________

Relationship of the Second Successor Attorney in Fact to the Principal: _________________________________________________

11. [__] Durable Power of Attorney for Health Care Decisions &

                           Advanced Health Care Directive

Full Legal Name of Principal/Declarant:

___________________________________________________________

Mailing Address of Principal:

___________________________________________________________

___________________________________________________________

Full Legal Name of the Individual to Serve as the Initial

Attorney in Fact:

___________________________________________________________

Mailing Address of the Attorney in Fact:

___________________________________________________________

___________________________________________________________

Relationship of the Initial Attorney in Fact to the

Principal:__________________________________________________

Full Legal Name of the Individual to Serve as the First

Successor Attorney in Fact:

___________________________________________________________

Mailing Address of the First Successor Attorney in Fact:

___________________________________________________________

___________________________________________________________

Relationship of the First Successor Attorney in Fact to the

Principal:__________________________________________________

Full Legal Name of the Individual to Serve as the Second

Successor Attorney in Fact:

___________________________________________________________

Mailing Address of the Second Successor Attorney in Fact:

___________________________________________________________

___________________________________________________________

Relationship of the Second Successor Attorney in Fact to the Principal:__________________________________________________

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IMPORTANT NOTES*

1. By signing this form you agree this form will serve as the written agreement between yourself and Michael J. Denk, Attorney at Law and Missouri Estate Planning, LLC, to draft and provide you with one (1) Durable Power of Attorney for Personal Financial Decisions and/or one (1) Durable Power of Attorney for Health Care Decisions & Advanced Health Care Directive (at the cost of $195 per document requested) per your request and based upon the information you provide on this form. You understand and agree no other drafting services are being provided to you.

2. The signing and proper notarization of your Durable Power of Attorney document(s) is YOUR responsibility.

3. You understand and agree no legal advice is being provided to to you and you should consult with an Attorney of your choice for such legal advice.

4. In your behalf and on behalf of your estate you hereby release and hold harmless Michael J. Denk, Attorney at Law and Missouri Estate Planning, LLC, from any and all claims relating to your use and implementation of such Durable Power of Attorney documents.