To see if the "Simple Life Plan" is right for you OLD FORM

A Living Will expresses your personal wishes for end-of-life care.

A Health Care Surrogate Designation appoints one or more persons to make health care decisions for you if you a not able to make those decisions. It also allows this person or persons to speak with your health care providers and obtain your medical records.

A will names the person or persons who will receive your property and assets after your death. It also appoints a person or persons to gather your property and assets, pay your debts, and distribute your assets under court supervision.

Please understand that property or assets that have joint owners (such as real estate, vehicles, and bank accounts), will pass to the other owner upon your death regardless of what your will says. In addition, assets that list one or more beneficiaries (such as retirement accounts, life insurance, annuities, and some financial accounts), will pass to those beneficiaries upon your death regardless of what your will says. If you do not want this property or assets to pass to those persons, please ask whether a more advanced life plan is appropriate for you (such as a trust, special deed, re-titling of assets, asset transfer, etc.).

A power of attorney (POA) appoints one or more people to perform legal and financial transactions for you. This is very important if you are temporarily or permanently incapacitated and will allow your agent to manage your affairs and preserve your assets. However, a power of attorney is effective immediately. If your agent has the original or a copy of the POA, he or she can access your assets and sign legal documents for you.

If you do not need an agent to perform legal and financial transactions for you now, I recommend that you do not create copies of your POA. Keep the POA in a secure location and inform your agent or another person where they can obtain the POA if you become incapacitated.

When choosing an agent for your POA, be as careful as possible to choose someone completely trustworthy. If you have any doubts at all about a person’s ability to resist temptation and act only in your interests, I recommend that you appoint two people to serve together.

To obtain your Simple Life Plan package, please provide the following information:

Name as printed on your birth certificate*

First NameMiddle NameLast NameSuffix

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

HEALTH CARE SURROGATE: Who will you designate to make health care decisions for you if you are not able to make your own decisions?

Full Name of Health Care Surrogate

First NameMiddle NameLast NameSuffix

Address of Health Care Surrogate

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number of Health Care Surrogate

Area CodePhone Number

ALTERNATE HEALTH CARE SURROGATE: If your primary health care surrogate cannot serve as your surrogate, who will you designate?

Full Name of Alternate Health Surrogate

First NameMiddle NameLast NameSuffix

Address of Alternate Health Surrogate

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number of Alternate Health Surrogate

Area CodePhone Number

Would you like to include a Living Will with your documents? Living Wills express personal wishes for end of life care. If you do not want heroic measures at end of life, you should prepare a Living Will.

YesNo

Do you have special concerns or considerations about emergency or end of life care (such as specific religious preferences)?

LAST WILL AND TESTAMENT: Who will you designate to administer your Estate according to your will?

PLEASE NOTE: Florida law requires that the Personal Representative be a relative or resident of the State of Florida. Out-of-state friends are not eligible to serve as personal representative.

Full Name of Personal Representative to administer your will:

First NameMiddle NameLast NameSuffix

Personal Representative's Relationship to You

ALTERNATE PERSONAL REPRESENTATIVE: If this person cannot serve, who will you designate as an alternate?

Full Name of Alternate Personal Representative:

First NameMiddle NameLast NameSuffix

Alternate Personal Representative's Relationship to You

Do you have concerns that these people cannot be trusted to carry out your wishes faithfully?

YesNo

BENEFICIARIES: To whom would you like to give your property after your death (beneficiaries)? You can give everything to one person, or you can give specific items to specific people, or you can give a percentage of your estate to specific people. You can also give your property to charities.

Do you own a home?

YesNo

If you own a home, to whom do you want to give the home?

Full Name of the Beneficiary to your Home

First NameMiddle NameLast NameSuffix

Do you have minor children

YesNo

Please list names of your minor children below.

Who would you like to serve as guardian for your minor children? (The children’s other biological parent will have priority over this person)

Full Name of Guardian

First NameMiddle NameLast NameSuffix

Address of Guardian

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Do you plan to have children in the future?

YesNo

Do you wish to express a choice of burial, cremation, memorial or funeral arrangements?

YesNo

If yes, what choice do you wish to express?

Do you wish to execute a power of attorney?

Yes (please complete section below)No

AGENT UNDER POWER OF ATTORNEY: Who will you designate as your agent for the power of attorney?

Full Name of agent

First NameMiddle NameLast NameSuffix

Address of agent

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

If the person you are appointing as agent cannot serve or is unable to serve as your agent, who will you designate?

Full Name of alternate agent

First NameMiddle NameLast NameSuffix

Address of alternate agent

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Are you concerned that any person may attempt to challenge your choices and decisions? (If you answer Yes to this question, I will discuss these matters with you personally before preparing your documents.)

YesNo

Do you have questions or concerns about specific documents, choices, assets, or matters? Please explain briefly so that I can discuss these with you:

Do you want to list the names of your family members in your Will? If so, please type their names as you want them to appear in the Will and their relationship to you.

Please type your name below to indicate that you read and understand the introductory information about the documents in the Simple Life Plan Package, provided the information on this form, ensured that the information accurately reflects your personal choices, and you wish to have legal documents prepared to carry out your choices.

Full Name

First NameMiddle NameLast NameSuffix

To see if the "Simple Life Plan" is right for you, please answer the following questions

SIMPLE LIFE PLAN QUESTIONNAIRE