Adair & Baker: PoA Questionnaire

General Financial Power of Attorney

Intake Form
Your Information

This is information about you - not anyone else like your AIF/Appointee, or a family member.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number
Date of Birth

MonthDayYear
Date
Email
example@example.com
Your Attorney-in-Fact/Appointee(s)

Who do you wish to appoint as your Attorney-in-Fact (AIF, or Appointee)? This is the person appointed by you to handle your affairs (as outlined in the Power of Attorney) if you are unable to act for yourself.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If the Appointee named above cannot or will not serve in that capacity, who do you wish to name as the successor Appointee?
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If the successor Appointee named above cannot or will not serve in that capacity, who do you wish to name as the second successor Appointee?
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legal Permissions

What powers orpermissions do you wish your AIF or Appointee to have in case you are unable to act for yourself?
Do you wish the AIF/Appointee to have all the general powers?

YESNO
If "NO", which of the following powers do you wish them to have?

Real PropertyTangible Personal PropertyStocks & BondsCommodities & OptionsBanks & Financial InstitutionsOperation of entity or businessInsurance & AnnuitiesEstates, Trusts, and other Beneficial InterestsClaims & LitigationPersonal & FamilyMaintenanceBenefits from Governmental Programs or Civil or Military ServicesRetirement PlansTaxesAll of the Above
Specific Powers: Do you want your AIF/Appointee to have any of the following specific powers?

Create, fund, amend, or terminate an inter vivos trustMake a gift subject to the limitations of OCGA 10-6B-56 and any Special Instructions in the Power of AttorneyCreate or change rights of survivorshipCreate or change a beneficiary designationAuthorize another person to exercise the authority granted under this Power of AttorneyWaive your right to be a beneficiary of a joint and survivorship annuity, including a survivor benefit under a retirement planExercise authority over the content of electronic communications sent or received by youExercise fiduciary powers that you have authority to delegate and that are expressly and clearly identified in the Special InstructionsRenounce, disclaim or refuse an interest in property, including a power of appointment
HIPAA: Will HIPAA documents be under the AIF/Appointee's authority?

YESNO
Date of Effect

I want my above stated wishes to take effect on the following date:
I want my above stated wishes to take immediate effect

YESNO
If "NO", I want my above stated wishes to take effect on the following date

MonthDayYear
Date
Should be Empty:

General Financial Power of Attorney

Your Information

Your Attorney-in-Fact/Appointee(s)

Legal Permissions

Date of Effect