THE HARRIS FIRM LLC - LIVING WILLS & POWERS OF ATTORNEY Preferred Method of Payment (You DO NOT Have to Make a Payment When You Submit the Questionnaire)*Please Let Us Know How You Are Going to Make a Payment. If You Pay On the Website, then we can get you the documents or set up an appointment to meet the attorney in an office to sign everything in person and get your case filed! Credit/Debit Card Online Drop off at office Set up Appointment with Attorney Your Full Name*Your Address (including County that you live in)*Your Phone Number*Your Email Address*Your Date of Birth*Your Social Security Number (or at least the last four digits)*If Needing a LIVING WILL, please list the name, relationship to you, date of birth, address, and relationship to you of the individual you would like to be appointed as Health Care Proxy.A Health Care Proxy would be the person appointed to make health related life or death decisions should you become incapacitated. Please list an alternate individual should the first choice be deceased at the time or unwilling to be your proxy. You can also list a third person/alternate if you like.If needing a living will, please state whether you would prefer to stop life sustaining treatment (such as machines keeping you alive, etc.) continue keeping you alive or be discontinued.You can have your health care proxy you appoint override this preference (which is usually how people handle this) but your preference is usually stated in the Living Will for the proxy to decide whether to follow it or not based on the circumstances of your condition at that time. If you are requesting a Power of Attorney, then list who you are appointing as Power of Attorney.Please just list their name, date of birth, address, and relationship to you.If needing a Power of Attorney, then please list what types of things you would like this Power of Attorney to be able to make decisions for you.CommentsThis field is for validation purposes and should be left unchanged.