CONFIDENTIAL ESTATE PLANNING SURVEY

PART 4: WHO WILL BE HANDLING YOUR AFFAIRS?
List the individual(s) you wish to serve as agents for your health care and financial decisions. You may designate individual agents, or co-agents. We will discuss your designations further when we meet.
LIVING TRUST
Your Trustee is responsible for managing property titled in the name of your Living Trust under the terms of your Trust. List the person(s) you wish to act as your Initial and Successor Trustees. Most people who create a revocable living trust are the initial Trustee, and designate Successor Trustees who will serve
You
Initial Trustee
Spouse
Initial Trustee
Name
Name
Address
Address
Home Phone
Home Phone
Cell Phone
Cell Phone
Email
Email
Relationship to You
Relationship to You
First Successor Trustee
First Successor Trustee
Name
Name
Address
Address
Home Phone
Home Phone
Cell Phone
Cell Phone
Email
Email
Relationship to You
Relationship to You
Second Successor Trustee
Second Successor Trustee
Name
Name
Address
Address
Home Phone
Home Phone
Cell Phone
Cell Phone
Email
Email
Relationship to You
Relationship to You
LAST WILL
Your Personal Representative is responsible for probating your Will, if probate is necessary, and distributing your assets to your beneficiaries. List below all persons you wish to act as the primary and alternate Personal Representatives. We will review these designations with you and verify that these individuals qualify to serve as Personal Representative under Florida law.
You
Primary Personal Representative
Spouse, If Different
Primary Personal Representative
Name
Name
City and State
City and State
Relationship to You
Relationship to You
First Alternate Personal Representative
First Alternate Personal Representative
Name
Name
City and State
City and State
Relationship to You
Relationship to You
Second Alternate Personal Representative
Second Alternate Personal Representative
Name
Name
City and State
City and State
Relationship to You
Relationship to You
DURABLE PROPERTY POWER OF ATTORNEY
Your designated agent is authorized to handle all of your personal financial affairs that are not in your Trust, including, but not limited to, real estate sales, bank account transactions, execution of contracts, tax returns and motor vehicle registrations.
You
Primary Agent
Spouse, If Different
Primary Agent
Name
Name
Address
Address
Home Phone
Home Phone
Cell Phone
Cell Phone
Email
Email
Relationship to You
Relationship to You
First Alternate Agent
First Alternate Agent
Name
Name
Address
Address
Home Phone
Home Phone
Cell Phone
Cell Phone
Email
Email
Relationship to You
Relationship to You
Second Alternate Agent
Second Alternate Agent
Name
Name
Address
Address
Home Phone
Home Phone
Cell Phone
Cell Phone
Email
Email
Relationship to You
Relationship to You

DESIGNATION OF HEALTH CARE SURROGATE
Your designated Health Care Surrogate is authorized to make your health care decisions in the event you cannot do so yourself. Decisions include but are not limited to terminating life supports, consenting to/refusing surgery and medical procedures, obtaining medical records, admitting you to a nursing home.
You
Primary
Spouse, If Different
Primary
Name
Name
Address
Address
Home Phone
Home Phone
Cell Phone
Cell Phone
Email
Email
Relationship to You
Relationship to You
First Alternate
First Alternate
Name
Name
Address
Address
Home Phone
Home Phone
Cell Phone
Cell Phone
Email
Email
Relationship to You
Relationship to You
Second Alternate
Second Alternate
Name
Name
Address
Address
Home Phone
Home Phone
Cell Phone
Cell Phone
Email
Email
Relationship to You
Relationship to You
List the names of anyone you want to allow to obtain your medical information during your lifetime, in addition to the Health Care Surrogate(s) you named in the previous section.
Name
Name
Name
Name
MINOR CHILDREN
If you have minor children, you should appoint a guardian to care for them (“Guardian of the Person”), and a guardian to handle their finances (“Guardian of the Property”) in the event both parents die before the children reach age 18. You may also appoint a married couple as co-guardians.
GUARDIAN OF THE PERSON:
Primary Guardian of the Person
GUARDIAN OF THE PROPERTY (FINANCES):
Primary Guardian of the Property
Name
Name
City and State
City and State
Relationship to You
Relationship to You
First Alternate Guardian of the Person
First Alternate Guardian of the Property
Name
Name
City and State
City and State
Relationship to You
Relationship to You
Second Alternate Guardian of the Person
Second Alternate Guardian of the Property
Name
Name
City and State
City and State
Relationship to You
Relationship to You

Bank Name	Account #	Account Type (Checkings / Savings / CD)	Owner (Husband / Wife / Husband & Wife / Husband & Other / Wife & Other / Trust)	Approx Value $	If transferable on death or payable on death, to whom?

Broker	Owner (Husband / Wife / Husband & Wife / Husband & Other / Wife & Other / Trust)	Approx Value $	If transferable on death or payable on death, to whom?

Company	Owner (Husband / Wife / Trust)	Insured Party (Husband / Wife / Trust)	Cash Value $	Death Value $	Beneficiary

Address	Owner (Husband / Wife / Husband & Wife / Trust)	Mortgage Amount $	Approx Value $

Husband / Wife	Soc Sec/Month $	Pension/Month $	Veterans Benefits/Month $	Other Income/Month $

CONFIDENTIAL ESTATE PLANNING SURVEY

Step 1 of 6

PART 1: GENERAL INFORMATION

Name, Address & Tel. No. of person filling out this form (if other than client):

Children:

PART 2: BENEFICIARIES

PART 3: FINANCIAL INFORMATION

PART 4: WHO WILL BE HANDLING YOUR AFFAIRS?

LIVING TRUST

LAST WILL

DURABLE PROPERTY POWER OF ATTORNEY

DESIGNATION OF HEALTH CARE SURROGATE

MINOR CHILDREN

PART 5: DOCUMENTS TO BRING TO YOUR CONSULTATION

PART 6: YOUR QUESTIONS/ADDENDUM

Palm Beach GArdens

Boynton Beach

Port St. Lucie

Stock	Owner (Husband / Wife / Husband & Wife / Husband & Other / Wife & Other / Trust)	Approx Value $

Borrower	Owner (Husband / Wife / Husband & Wife / Trust)	Approx Value $