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 NameOther or former namesSocial Security number (last 4 digits)Spouse’sHome addressIs 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 PlaceHome phoneWork phoneCellE-Mail: Are you a U.S. citizen? Yes No If U.S. citizen other than by birth, state date of CitizenshipOccupationSpouse’s Full NameSpouse’s Other or former Name(s):Spouse’s cell numberWorkIs your Spouse a U.S. citizen? Yes No If U.S. citizen other than by birth, state date of citizenshipDo you have Children (including stepchildren or foster children)? Yes No If yes, please provide the following information for each:NameDOB/Birth date Date Format: MM slash DD slash YYYY Married? Yes No State of ResidenceNameDOB/Birth date Date Format: MM slash DD slash YYYY Married? Yes No State of ResidenceNameDOB/Birth date Date Format: 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:NameDOB/Birth date Date Format: MM slash DD slash YYYY Married? Yes No State of ResidenceNameDOB/Birth date Date Format: MM slash DD slash YYYY Married? Yes No State of ResidenceDo you have dependents other than minor children? If so, please provide name, age, date of birth and residence:NameDOB/Age Date Format: MM slash DD slash YYYY AddressPlease list your parents, brothers, sisters, and state whether they are living, and if so, list their City and State of residence.NameBrother/SisterLiving?City,StateNameBrother/SisterLiving?City,StateDo you presently have a Will? If so, what is the date on the WillWas 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 Date Format: 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 namesWho will receive your remaining tangible personal property? (Such as jewelry, pictures, electronic items, plants, etc.)Your Spouse? Yes No Other individual(s):NameRelation to youCity, StateNameRelation to youCity, StateWho will receive the remaining tangible personal property if your spouse does not survive you?NameRelation to youCity, StateNameRelation to youCity, StateNameRelation to youCity, 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? NameRelationCity, StateNameRelationCity, StateNameRelationCity, StatePERSONAL REPRESENTATIVE. Who will carry out the terms of the Will?NameAddress 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? NameAddress 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? NameAddress 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? NameAddress Street Address State / Province / Region ZIP / Postal Code Phone NumberEmail Who will be named Guardian for your minor children? NameAddress Street Address State / Province / Region ZIP / Postal Code Phone NumberEmail Who will serve as Guardian if your first choice is unable to serve?NameAddress 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 IdentificationLocationValueItem IdentificationLocationValueItem IdentificationLocationValueItem IdentificationLocationValueIntangible property: stocks and bonds, government bills, notes; commoditiesItem IdentificationLocationValueItem IdentificationLocationValueItem IdentificationLocationValuePersonal Property: automobiles; other vehicles (airplanes, boats, motorcycles, recreational vehicles); precious metals; safe deposit contents, collectibles, art;Item IdentificationLocationValueItem IdentificationLocationValueItem IdentificationLocationValue 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.)NameAddress 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? NameAddress 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? NameAddress 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?NameAddress 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?NameAddress 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? NameAddress 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 DoctorAddressPhone #Name of DoctorAddressPhone #Name of DoctorAddressPhone #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.NameAddressPhone #NameAddressPhone #NameAddressPhone #
