Lizbeth Potts, P.A. 9385 North 56th Street, Ste. 311 Temple Terrace, Florida 33617 (813) 988-9190 [email protected] WILL AND ADVANCE DIRECTIVE INFORMATION Step 1 of 7 14% Part I. Family Data:Full Name Other or former names Social Security number (last 4 digits)Spouse’s Home address Is this your homestead? Yes No Do you have any other residences? Yes No Where? * Please provide deeds or other information regarding these other properties.Birthdate MM slash DD slash YYYY Birth Place Home phoneWork phoneCellE-Mail: Are you a U.S. citizen? Yes No If U.S. citizen other than by birth, state date of Citizenship Occupation Spouse’s Full Name Spouse’s Other or former Name(s): Spouse’s cell numberWork Is your Spouse a U.S. citizen? Yes No If U.S. citizen other than by birth, state date of citizenship Do you have Children (including stepchildren or foster children)? Yes No If yes, please provide the following information for each:Name DOB/Birth date MM slash DD slash YYYY Married? Yes No State of Residence Name DOB/Birth date MM slash DD slash YYYY Married? Yes No State of Residence Name DOB/Birth date MM slash DD slash YYYY Married? Yes No State of Residence List the name of any child(ren) and their other parent if not your present spouse:Name DOB/Birth date MM slash DD slash YYYY Married? Yes No State of Residence Name DOB/Birth date MM slash DD slash YYYY Married? Yes No State of Residence Do you have dependents other than minor children? If so, please provide name, age, date of birth and residence:Name DOB/Age MM slash DD slash YYYY Address Please list your parents, brothers, sisters, and state whether they are living, and if so, list their City and State of residence.Name Brother/Sister Living? City,State Name Brother/Sister Living? City,State Do you presently have a Will? If so, what is the date on the Will Was it signed in Florida? Yes No If not where? Have you signed a prenuptial or postnuptial agreement Yes No If so, what is the date of the agreement MM slash DD slash YYYY Is the agreement still in force? Yes No What is the maiden name of your spouse according to the prenuptial agreement? Part II. Beneficiary:Will your Spouse be included as a beneficiary in this Will? Yes No If so, do you want to include a simultaneous death clause? Yes No Are any of your children intentionally excluded as beneficiaries of this Will? Yes No If so, please list their full names Who will receive your remaining tangible personal property? (Such as jewelry, pictures, electronic items, plants, etc.)Your Spouse? Yes No Other individual(s):Name Relation to you City, State Name Relation to you City, State Who will receive the remaining tangible personal property if your spouse does not survive you?Name Relation to you City, State Name Relation to you City, State Name Relation to you City, State Who will receive the residuary estate? (Any property/proceeds remaining after the satisfaction of any gifts and payments to creditors)?Your spouse? Yes No Who will receive the residuary estate if your spouse does not survive you? Who will receive the residuary estate if the Beneficiary does not survive you? What percentage of the residuary estate will your spouse receive? How will this share be distributed if your spouse does not survive you? Who would you want to receive it? Name Relation City, State Name Relation City, State Name Relation City, State PERSONAL REPRESENTATIVE. Who will carry out the terms of the Will?Name Address Street Address State / Province / Region ZIP / Postal Code Phone NumberEmail Will the Personal Representative serve with or without a bond? Yes No Who will carry out the terms of the Will if the Personal Representative is unable to serve? Name Address Street Address State / Province / Region ZIP / Postal Code Phone NumberEmail Part III. Children’s Trust: What percentage of the residuary estate will the Children’s Trust receive? What percentage of the residuary estate will your children receive outright (not in Trust)? What age must all your children reach before the assets are distributed outright to them rather than used for their benefit? Will the final distribution of the remaining Children’s Trust assets be made in one lump or installments? Eplain.Who will carry out the terms of the Children’s Trust? Who will be the Trustee? Name Address Street Address State / Province / Region ZIP / Postal Code Phone NumberEmail Will the Trustee serve with or without bond? Yes No Who will carry out the terms of the Trust if the Trustee is unable to? Name Address Street Address State / Province / Region ZIP / Postal Code Phone NumberEmail Who will be named Guardian for your minor children? Name Address Street Address State / Province / Region ZIP / Postal Code Phone NumberEmail Who will serve as Guardian if your first choice is unable to serve?Name Address Street Address State / Province / Region ZIP / Postal Code Phone NumberEmail Part IV. Assets:Liquid Assets: cash (dividends, etc.); savings accounts; checking accounts; money market accounts; mutual fundsItem Identification Location ValueItem Identification Location ValueItem Identification Location ValueItem Identification Location ValueIntangible property: stocks and bonds, government bills, notes; commoditiesItem Identification Location Value Item Identification Location Value Item Identification Location Value Personal Property: automobiles; other vehicles (airplanes, boats, motorcycles, recreational vehicles); precious metals; safe deposit contents, collectibles, art;Item Identification Location Value Item Identification Location Value Item Identification Location Value Part V. Durable Power of Attorney:Who do you want to designate as your agent? (You grant someone the authority to act as your agent, which gives them the legal ability to produce a change in legal relations by doing whatever acts are authorized.)Name Address Street Address State / Province / Region ZIP / Postal Code Phone NumberEmail If the individual you designate as Agent cannot or chooses not to act as your Agent, who would you wish to designate? Name Address Street Address State / Province / Region ZIP / Postal Code Phone NumberEmail Part VI. Declaration Naming Pre-need Guardian: (If you are unable to care for yourself because of poor health, disability, or incapacity and needed someone to have legal authority and duty to care for you and your property)Who do you want as your Pre-need Guardian? Name Address Street Address State / Province / Region ZIP / Postal Code Phone NumberEmail If this individual is unable or chooses not to be the Pre-need Guardian, who would you prefer?Name Address Street Address State / Province / Region ZIP / Postal Code Phone NumberEmail Part VIII. Living Will and Health Care Surrogate: (Your “medical mouthpiece”. If you were unable to tell medical personnel what you want/do not want in regards to medical treatment.)Who would you want to be your Health Care Surrogate?Name Address Street Address State / Province / Region ZIP / Postal Code Phone NumberEmail If the person mentioned above is unable or unwilling to perform his or her duties, who would you want to designate? Name Address Street Address State / Province / Region ZIP / Postal Code Phone NumberEmail Who would you want notified regarding the designation of the Health Care Surrogate, such as your physician(s)? Name of Doctor Address Phone #Name of Doctor Address Phone #Name of Doctor Address Phone #Part IX. Health Insurance Portability and Accountability Act (HIPAA) Release Information. List the person who you would like your medical information to be released to in order to talk to insurance company(ies), medical personnel, medical facility(ies). The individual you have chosen to be your Health Care Surrogate and the back-up Health Care Surrogate should be on this list.Name Address Phone #Name Address Phone #Name Address Phone #PhoneThis field is for validation purposes and should be left unchanged. Δ
