Name: Lizbeth Potts, Attorney at Law
Address: 9385 N 56th St Suite 311, Tampa, FL, 33617, US
Telephone: +1 8139889190

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
Date Format: MM slash DD slash YYYY
Birth Place
Home phone
Work phone
Cell
E-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 number
Work
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
Date Format: MM slash DD slash YYYY
Married?
- Yes
- No
State of Residence
Name
DOB/Birth date
Date Format: MM slash DD slash YYYY
Married?
- Yes
- No
State of Residence
Name
DOB/Birth date
Date Format: MM slash DD slash YYYY
Married?
- Yes
- No
State of Residence

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 Number
Email
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 Number
Email

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 Number
Email
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 Number
Email
Who will be named Guardian for your minor children?
Name
Address
Street Address State / Province / Region ZIP / Postal Code
Phone Number
Email
Who will serve as Guardian if your first choice is unable to serve?
Name
Address
Street Address State / Province / Region ZIP / Postal Code
Phone Number
Email

Part IV. Assets:
Liquid Assets: cash (dividends, etc.); savings accounts; checking accounts; money market accounts; mutual funds
Item Identification
Location
Value
Item Identification
Location
Value
Item Identification
Location
Value
Item Identification
Location
Value
Intangible property: stocks and bonds, government bills, notes; commodities
Item 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 Number
Email
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 Number
Email
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 Number
Email
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 Number
Email
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 Number
Email
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 Number
Email
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 #

WILL AND ADVANCE DIRECTIVE INFORMATION

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