Supplemental Estate Planning Intake Form Single Person Page 2

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4. Which areas do you intend to authorize your agent and any successor agent to act for
you under the power of attorney:
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 or Civil or Military Service
Retirement Plans
Taxes
All Preceding Subjects
Health Care Power of Attorney
1. Do you intend for the Health Care Power of Attorney to expire on a certain date or
after the occurrence of a specific event?
Yes
No
If yes, please provide additional information:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Living Will
1. Do you intend for this declaration to apply when you are in a terminal condition, in a
permanently unconscious state, or both?
Terminal Condition Only
Permanently Unconscious State Only
Both
Supplemental Estate Planning Intake Form – Single Person – Version 14.1
Page 2 of 4

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