Florida Durable Power of Attorney Intake Form (Non-Lawyer)*

Florida Durable Power of Attorney Intake Form (Non-Lawyer)

Complete this form to provide information needed to prepare your Florida Durable Power of Attorney. This service is provided by a non-lawyer preparer.
FLORIDA NON-LAWYER DISCLOSURE

Please read the following disclosure carefully BEFORE continuing:
1. The individual preparing this document is not an attorney licensed to practice law in the State of Florida and is not permitted to provide legal advice or determine your legal rights or remedies.
2. The preparer cannot and will not offer legal opinions, representation, or guidance on whether any choice is appropriate for your specific situation.
3. If you have questions about your legal rights or the legal effect of any document, you are encouraged to seek the services of a qualified attorney.
I understand that this service is provided by a non-lawyer and that no legal advice has been given.
Signature of principal acknowledging the non-lawyer disclosure above BEFORE completing the intake questions below.
Date of Acceptance of non-lawyer disclosure statement above.

MonthDayYear
Date
Terms & Conditions for Document Preparation Services

1. Scope of Services
The document preparation services provided are non‑lawyer services. The preparer is not an attorney licensed to practice law in the State of Florida and does not provide legal advice, legal representation, or legal opinions. All documents are prepared solely based on the information provided by the client, and the client is responsible for reviewing all documents for accuracy and completeness.

2. Client Responsibilities
The client agrees to provide accurate, complete, and truthful information necessary for document preparation.
The client understands that the preparer cannot advise whether a particular document, clause, or selection is appropriate for their legal situation.
The client is encouraged to consult with a licensed attorney for any legal questions or concerns.
3. Fees and Payment
All fees for document preparation services are due at the time of engagement.
Fees cover the preparation of the document(s) as requested and do not include additional services such as notarization, apostille processing, filing fees, courier fees, or government charges unless specifically listed.
Rush or expedited services, if requested, may incur additional fees.
4. Refund Policy
Because document preparation is a custom, service‑based process, all fees are non‑refundable once work has begun.
If the client chooses to discontinue the process after work has started, no refund will be issued.
If the preparer is unable to complete the service due to their own error or inability, a full refund will be issued.
No refunds will be issued for delays caused by the client, third parties, government agencies, or incomplete/incorrect information provided by the client.
5. Amendments and Revisions
The client is responsible for reviewing all documents upon receipt.
One round of minor revisions (such as spelling corrections, name adjustments, or formatting updates) is included if requested within five (5) business days of delivery.
Substantive changes such as new information to the current order, added sections, or changes in legal direction are considered new work and may incur additional fees.
Any amendments requested after the five‑day review period may also be subject to an additional charge of $25.00.
6. No Guarantee of Outcome
Document preparation services do not guarantee any legal outcome, approval, acceptance, or result by any court, agency, or third party. The client acknowledges that they are solely responsible for any decisions made regarding their legal matters.

7. Acknowledgment
By signing the intake form, the client acknowledges that they have read, understood, and agree to these Terms & Conditions and the accompanying Non‑Lawyer Disclosure Notice.
Signature of Principal acknowledging the terms and conditions of the document preparation service.
Client (Principal) Information
Full Legal Name
Date of Birth

MonthDayYear
Date
Florida Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Agent (Attorney-in-Fact) Information

The person who you will be giving powers to.
Full Legal Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Relationship to Principal
Would you like to name a Successor Agent?
Successor Agent (Optional)
Full Legal Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Relationship to Principal
Powers Granted
Select the powers you wish to grant to your Agent (Attorney-in-Fact):

Other
Under Florida law, gifting authority must be expressly granted and may have legal consequences. Please review carefully before selecting this option.
Medicaid Planning Warning: Under federal and Florida Medicaid rules, gifts or transfers of assets for less than fair market value may result in a Medicaid ineligibility penalty period. Granting gifting authority to your agent could impact your future eligibility for Medicaid long-term care benefits. You are strongly encouraged to consult with a qualified elder law attorney before granting gifting authority if Medicaid eligibility may be a concern.
I understand that gifting authority may affect Medicaid eligibility and I have chosen to proceed with this authority knowingly.
I understand that granting gifting authority may allow my agent to transfer my assets and I have chosen this intentionally.
Florida Durable Power of Attorney documents used for real estate transactions must be signed with the same formalities as a deed (two witnesses and notarization).
Enter specific information about the powers you wish to grant to your attorney-in-fact below, for example:

Real estate transactions: list the address of the property. If more than one property, list it in the "additional instructions or restrictions" Box below.

Banking & Financial Accounts: Checking account# 123456789, stock account# 34384758, Business account# 9876384, etc.

Business Operations: ABC roofing company
Enter the address of the real estate property you wish to give powers to your attorney-in-fact. Street Address Address Line 2 City State Zip
Enter specific financial account numbers (ie...checking, savings, stocks etc) you wish to give powers to your attorney-in-fact. Enter account number(s)
Business Operations Name of Business Street Address Address Line 2 City State Zip
Effective Date
When should this Power of Attorney become effective?
Please provide any additional instructions or restrictions for your Power of Attorney document:
Principal's acknowledgement
1. By submitting this form, you confirm that the information provided is accurate and complete to the best of your knowledge.
2. You understand that the preparer is not responsible for any legal consequences resulting from the use of this document.
3. You consent to the use of the information provided in this form for the preparation and notarization of your Durable Power of Attorney document.
4. You acknowledge that the preparer did not advise you on how to complete this form for your specific situation.
5. The preparation time-frame is 1-2 business days. Preparation time frame starts the business day following the date the payment is received by Beaches Notary and Apostille Service.
Signature of principal.
Date Signed

MonthDayYear
Date
Should be Empty:

Florida Durable Power of Attorney Intake Form (Non-Lawyer)

Client (Principal) Information

Agent (Attorney-in-Fact) Information

Successor Agent (Optional)

Powers Granted

Effective Date

Principal's acknowledgement