Short Form RLT - CDQ : Estate Planning - Integrated Trust Systems

Data Entry / MLCP™ Health Care Document Set

TIMED-PAGE NOTICE

Entry fields with a red asterisk (*) are minimally required for page submission.

1) CREATOR / SPOUSE PERSONAL INFORMATION

Creator:

Yes

*First Name

*Last Name

DOB

U.S. Citizen

Spouse:

Yes

First Name

Last Name

DOB

U.S. Citizen

Address:

*Street Address (or P.O. Box No.)

Unit

*City

*County/Parish

*State

*Zip Code

Contact:

*Daytime Phone

Other Phone

*E-mail Address

2) PERSONAL HEALTH CARE AGENT APPOINTEES

If you are married, it is assumed that your spouse will serve as your Primary Health Care Agent, if able, before the appointees listed below.

Client's Appointments:

1)				/
	First Name	Initial	Last Name		Relationship

2)				/
	First Name	Initial	Last Name		Relationship

Spouse's Appointments:

1)				/
	First Name	Initial	Last Name		Relationship

2)				/
	First Name	Initial	Last Name		Relationship

NOTES / COMMENTS / QUESTIONS

NOTICE TO PURCHASER: Entries in the "Notes/Comments/Questions" textbox below will be auto-posted and permanently recorded in your (forthcoming) Client Console's NotePad Message Center. Archived NotePad message entries can be made available, by your choosing, for viewing and additional text entry applications by your legal counsel and/or other select persons.

Make Your Health Care Document Set Order Here

Total Placement Fee > $395.00 w/MLCP Membership Options:
First Month Only (FREE) 1-year/$5.00 Monthly 1-year/$50.00 Annual

I/(We), the person(s) identified above as the Client (& Spouse) for the purposes of this transaction, now elect to purchase the My LifeCard Plan (MLCP) Health Care Document Set for the amount of the Placement and Membership Fees as defined in the Contract & Purchase Agreement linked hereunder. NOTE > You must click on the button below to view the Contract and Purchase Agreement and then the "I AGREE" button at the bottom of the Contract page:

Credit Card

Debit Card

(or)

TRY BEFORE YOU BUY

Bank Card No.

Card Verification No.

Exp. Date

Billing:


Card/Account Name		Street Address

City

State

Zip Code

By submitting this My LifeCard Plan^® Health Care Document Set Data Questionnaire, I/We, identified as the person(s) whose name(s) has/have been entered above, hereby attest and confirm that I/We have read the Contract & Purchase Agreement and fully understand and agree with all the terms and conditions prescribed therein and that its execution - by virtue of the submitting of this transaction / by activating the "Submit/Process" button - is an acceptance by me/us of all of its mutually protective covenants, terms and conditions, and agree that said Contract/Agreement is lawfully binding upon all parties identified therein.