Fill and Sign the Limited Power of Attorney Questionnaire Form

Limited Power of Attorney Questionnaire GENERAL INFORMATION Full Name: Address: Home Phone: Work Phone: Cell Phone: Email: Gender: Male Female Birth date: Social Security Number: Marital Status: Single Married Divorced Widowed Domestic Partnership Partner/Spouse’s Full Name: Address: Home Phone: Work Phone: Cell Phone: Email: Are you at least 18 years of age and of sound mind? Yes No When do you want this power of attorney for finances to take effect? Immediately Only if I become incapacitated Who will certify that you are incapacitated? Doctor Address: Work Phone: Cell Phone: Email: I wish to also have this doctor certify my incapacity: Doctor Address: Work Phone: Cell Phone: Email: I want my attorney-in-fact to choose one doctor two doctors How many attorney-in-facts do you want? Attorney-in-fact Full Name: Address: Home Phone: Work Phone: Cell Phone: Email: Attorney-in-fact Full Name: Address: Home Phone: Work Phone: Cell Phone: Email: Attorney-in-fact Full Name: Address: Home Phone: Work Phone: Cell Phone: Email: If more than one attorney-in-fact named: They must act by unanimous agreement They must act by majority agreement Each can act independently Do you want to name alternate attorney(s)-in-fact? Yes No If yes: 1 st alternate attorney-in-fact: Full Name: Address: Home Phone: Work Phone: Cell Phone: Email: 2 nd alternate attorney-in-fact: Full Name: Address: Home Phone: Work Phone: Cell Phone: Email: POWERS OF YOUR ATTORNE(S)Y-IN-FACT What type of matters do you want the attorney(s) in fact to have the power to conduct transactions/make decisions in?: Real estate, but may not sell my home Tangible personal property Stock and bond transactions Commodity and option transactions Banking and other financial institution transactions Business decisions Insurance and annuity matters Estate, trust, and beneficiary transactions Transfer items of your property into your living trust Legal actions Personal and family maintenance Benefits from social security, Medicare, Medicaid, or other governmental programs or military service Retirement plans Taxes Gifts Children Do you want your attorney(s)-in-fact to make reports? Yes No If yes, how often? If yes, reports to be submitted to: Full Name: Address: Home Phone: Work Phone: Cell Phone: Email: Do you want your attorney(s)-in-fact to delegate authority to other people? Yes No Do you want your attorney(s)-in-fact to care for your pets? Yes No If yes: Pet Name: Type of Animal: Veterinarian: Feeding requirements: Medications: Important notes about pet’s needs/behavior: May your attorney(s)-in-fact to benefit from actions taken on your behalf? Yes No May your attorney(s)-in-fact commingle your funds with his or her own? Yes No Do you want your attorney(s)-in-fact to be compensated for handling your affairs? Yes, a reasonable amount Yes, in the amount of No