SCHEDULE A

PERSONAL AND FAMILY INFORMATION                 DATE: ____________________

 Your Full Name ____________________________________________________________

How do you sign your name

____________________________________________

DOB______________________   

Occupation ____________________________________________                 

Firm ___________________________________________________

Office Address _____________________________________

Office Phone _________________

Social Security No. ________________________________________

Driver’s License #_______________________________________State:___________________

Email:____________________________________________________

 Home Address  ________________________________________________________________

 County_________________________________________________________

 Home Phone _______________________________

Cell Phone _________________________________

 E-Mail_____________________________________

 Children & Beneficiaries

FULL NAME _______________________________________________

ADDRESS_______________________________________

________________________________________________

DOB ___________________________________________

SELF-SUPPORTING? YES or NO

SOCIAL SECURITY NO. ___________________________

FULL NAME ______________________________________________

ADDRESS_______________________________________

________________________________________________

DOB ___________________________________________

SELF-SUPPORTING? YES or NO

SOCIAL SECURITY NO. ___________________________

FULL NAME ____________________________________________

ADDRESS_______________________________________

________________________________________________

DOB ___________________________________________

SELF-SUPPORTING? YES or NO

SOCIAL SECURITY NO. ____________________________

 If children are minors, please list first and second preference for guardians of person and/or property. (Note: it is best to name an individual rather than a couple.)  Please include their address and phone number:

 (a) Name: ____________________________________                   

 Address: ____________________________________

 (b) Name:_____________________________________

 Address:____________________________________

Other persons dependent upon you for support.

Name: _________________________________________

How related to you: _____________________________

 Do you have a will?                                 Yes              No        Date  ___________

Any former marriages?                            Yes            No      Date ____________

(a) Child Support                                  Yes            No        Explain __________________________

(b) Alimony                                          Yes            No        Explain __________________________

Do you have any type of business agreement (buy sell, cross purchase, employment contract, etc.) 

Yes      No      Date ____________________________  

Do you own an interest in a business? If yes, please explain.

Do you have a Trust? (Attach a Copy)    Yes            No        Date ____________________________  

Are you a United States citizen?            Yes            No

(a)        If not, what is your country of citizenship?  _______________________________________

(b)        If not, are you a U.S. resident alien?               Yes      No

Have you ever filed a State or Federal Gift Tax Return (Form 709)?

Yes      No        Years  _____________________________________________________________

As of January 1, 2025, have you  or your spouse (if married) made gifts, valued over $19,000 to individuals?  Yes        No

Have you declared bankruptcy? Yes    No    Date ______________

Have you ever lived in Arizona, California, Idaho, Louisiana, New Mexico, Nevada, Texas, Washington or Wisconsin? Yes      No      If yes, please list any property you acquired while living there that you still own.

Advisers:   (Names, addresses and telephone numbers)

_______________________________________________________________

_______________________________________________________________

(Other Attorney: (Names, addresses and telephone numbers)

_______________________________________________________________

_______________________________________________________________

Accountant: (Names, addresses and telephone numbers)

_______________________________________________________________

_______________________________________________________________

Life insurance adviser:  (Names, addresses and telephone numbers)

_______________________________________________________________

_______________________________________________________________

Banker and trust officers:  (Names, addresses and telephone numbers)

_______________________________________________________________

_______________________________________________________________

Stockbrokers:  (Names, addresses and telephone numbers)

_______________________________________________________________

_______________________________________________________________

Investment adviser:  (Names, addresses and telephone numbers)

_______________________________________________________________

_______________________________________________________________

 Physician:   (Names, addresses and telephone numbers)

_______________________________________________________________

_______________________________________________________________

                                                           SCHEDULE B

Upon your death, how and to whom do you want your assets distributed? Please list names and birth dates.

If you die prematurely, should children receive property at age 18 or should it be held to a more mature age?

Do any of your children or grandchildren have special educational, medical or financial needs? 

If none of your children are living at your death, do you want your estate to go to:

Your family?                           Elsewhere? __________________

Do you wish to consider charitable bequests?                         Yes      No

 If yes, please provide further details:

Would you like to be an organ/tissue donor?                        Yes      No

Who would you like to designate as your Personal Representative (PR) to handle probate (administer your estate)? (If married, your spouse is usually the first named.)

(a) _____________________________________________________________

________________________________________________________________

Name, Relationship, Phone, Address, City, Zip, and County of residence

(b)________________________________________________________________

___________________________________________________________________

 Alternate PR, Relationship, Phone, Address, City, Zip, and County of residence

Who would you like to name as your agent (Durable Power of Attorney) should you become mentally incapacitated? (This is to handle your financial affairs like paying bills. If married, your spouse is usually named, then an alternate person.)

(a) _____________________________________________________________

________________________________________________________________

Name, Phone, Address, City, Zip, County of residence, Phone and Date of Birth

(b)______________________________________________________________

_________________________________________________________________

Alternate Name, Phone, Address, City, Zip, County of residence, Phone and Date of Birth

Please check each subject you want to include in the Agent’s General Authority. If you wish to grant general authority over all of the subjects you may check “All Preceding Subjects” instead of marking each subject.

           (____)  Real Property

            (____)  Tangible Personal Property

            (____)  Stocks and Bonds

            (____)  Commodities and Options

            (____)  Banks and Other Financial Institutions

            (____)  Operation of Entity or Business

             (____)  Insurance and Annuities

             (____)  Estates, Trusts and other Beneficial Interests

              (____)  Claims and Litigation

              (____)  Personal and Family Maintenance

              (____)  Benefits from Governmental Programs (including Medicare, Medicaid, Social Security, Social Security, Social Security Disability, VA and IRS)

              (____)  Civil or Military Service

              (____)  Retirement Plans

              (____)  Real Property

              (____)  Taxes

 (____)  All Preceding Subjects

Please check each subject you want to include in the Agent’s Specific Authority. (CAUTION: Granting any of  the following will give your Agent the authority to take actions that could significantly reduce your property or change how your property is distributed upon your death. We DO NOT recommend all of the following specific powers, but they are available to your Agent should you want them and we will discuss them.

(____)  Create, amend, revoke, or terminate an inter vivos (revocable or living) trust

(____)  Make a gift, subject to the limitations of the Uniform Power of Attorney Act, Chapter 709 and any special instructions in this Power of Attorney

(____)  Create or change the right of survivorship

(____)   Create or change a beneficiary designation

(____)  Authorize another person to exercise the authority granted under this power of attorney

(____)  Waive the principal’s right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan

(____)  Exercise fiduciary powers that the Principal has authority to delegate

(____)  Disclaim or refuse an interest in property, including a power of appointment

Who would you like to name as your Health Care Surrogate and Living Will designee should you become incapacitated and in a terminal situation?  (This is for healthcare and “end of life” decisions.)

(a) _____________________________________________________________

________________________________________________________________

Name, Phone, Address, City, Zip, County of residence, Phone

(b) _____________________________________________________________

________________________________________________________________

Alternate Name, Phone, Address, City, Zip, County of residence, Phone

If setting up a trust for the support of minors, disbursements can be based on any age of child or event-based timing. (I recommend disbursements distributed over time rather than outright upon 18 years old.) Please list any you desire.

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

During your lifetime, you will be the Trustee of your Trust(s) and retain full control.  Please name two successor Trustees to manage your Trust(s) in the event you cannot serve due to death or incapacity.  I recommend you name someone you trust and who is good with finances.

Your First Successor Trustee ______________________________________Relationship _________________

                                                                  City & State of Residence_________________________________

Your Second Successor Trustee ______________________________________Relationship_______________

                                                                  City & State of Residence_________________________________

If setting up a trust for the support of minors and/or dependents, disbursements from the estate can be  designated as (choose one please) 

Interest only, Interest & Principal, PR Discretion, or Other (Please explain)

 ___________________________________________________________________

____________________________________________________________________

___________________________________________________________________

If specific gifts designated for beneficiaries are no longer in your estate at your death, do you want a financial substitution made, an alternate gift decided by the PR, or no gift?  _______________________________________________

Name any descendants or ascendants (family members) you intend NOT to provide for in your estate

___________________________________________________________________

____________________________________________________________________

What are your funeral and burial/cremation directions for your remains?

___________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Where will your estate planning documents be kept? ___________________________________________________________________

SCHEDULE C

          1.  NET WORTH* As of ____________________________

Checking Account Bank & Balance

_____________________ $_________________

_____________________ $_________________

_____________________ $_________________

Savings Account Bank & Balance

_____________________ $_________________

_____________________ $_________________

CD's Bank & Balance

_____________________ $_________________

_____________________ $_________________

Money Market Funds Investment Firm & Balance

_____________________ $_________________

_____________________ $_________________

Bonds Name & Balance

_____________________ $_________________

_____________________ $_________________

Stocks Investment Firm & Balance

_____________________ $_________________

_____________________ $_________________

Practice or Business Name & value

_____________________ $_________________

_____________________ $_________________

Notes Receivable, etc. Name of Borrower & Amount

____________________ $_________________

_____________________ $_________________

Life Ins. Company & Value

____________________ $_________________

_____________________ $_________________

Annuities (Lump Sum) Name & Value

____________________ $_________________

_____________________ $_________________

Profit Sharing Company & Value

____________________ $_________________

_____________________ $_________________

Keogh/IRA/S.E.P. Name & Value

____________________ $_________________

_____________________ $_________________

Real Estate-home Address & Value

____________________ $_________________

Real Estate-other

____________________ $_________________

Is this rental or vacation home? _______________________________

Autos, Boats, Airplanes, etc. Make, Model, Year & Value

___________________________________________________________

___________________________________________________________

___________________________________________________________

Other personal prop, i.e., Antiques, coin collections

___________________________________________________________

___________________________________________________________

___________________________________________________________

OTAL ASSETS    $_________________________________

TOTAL LIABILITIES $_____________________________

*   Asset and liability categories should be listed in gross (e.g. bank accounts, stocks, bonds, CD's, bank loans, credit cards, etc.).  Breakdown of individual assets and liabilities may be scheduled and identified on back of form or on a separate statement.   Similarly, footnote any asset held jointly with someone other than spouse, with whom so held, their relationship to you, when joint interest was created, amount contributed by each joint tenant, and type (e.g. right of survivorship, tenancy in common). 

Do you expect any inheritance?

                  (a)   Yes           No

Estimated Amount of net share   $                                                                                   

Pension plan information

COMPANY _______________________________________________________

PLAN (IRA, IRA rollover, cash or deferred defined benefit profit sharing, non-qualified, etc.)

___________________________________________________________

___________________________________________________________

___________________________________________________________

VALUE (As of _______)

DESIGNATED BENEFICIARIES _______________________________

   PLEASE SEND TO Lynn@mootlawfirm.com FOR OUR INTIAL MEETING

1.  THIS COMPLETED QUESTIONAIRE 

2.   COPY of YOUR DRIVER’S LICENSE OR FLORIDA ID

Moot Law Firm, PLLC.

8996 Barco Lane

Jacksonville, FL 32222

(407) 375-1856