Your full name (first, middle, last)

E-mail address

Date of birth

Social security number

Address (physical, not P.O. Box)

Telephone number (with area code)

Who would you like to name as your “Agent-in-Fact” (i.e., the person to whom you will delegate your financial authority to)?
First, middle and last name

Address

Phone number (with area code)

Would you like your DPA to take effect immediately or only upon your incapacity (i.e., “springing”)? Immediately
Springing (after incapacity)

If you would like a springing DPA, who would you like to determine your incapacity?
A physician you name in your DPA (If this is your choice, please state name here).

OR

Doctor(s) chosen by your Agent-in-fact (state whether you would like your Agent to have one or two doctors make the determination of your incapacity).
1
2

Now, you must specify exactly what authority you would like to delegate to your Agent-in-fact:
(1) Real estate transactions.
(2) Tangible personal property transactions.
(3) Stock and bond, commodity, option and other securities transactions.
(4) Banking and other financial institution transactions.
(5) Business operating transactions.
(6) Insurance and annuity transactions.
(7) Estate, trust, and other beneficiary transactions.
(8) Living trust transactions.
(9) Legal actions.
(10) Personal and family care.
(11) Government benefits.
(12) Retirement plan transactions.
(13) Tax matters.
(14) Gift transactions.

Would you like to name a back-up Agent-in-Fact, in case your primary choice is unable/unwilling to act in this capacity?
No
Yes (please give full name of back-up, including phone/address).

COMMENTS
If you have any further instructions, requests or have need of clarification, please enter that information here before submitting your completed form. Once you have submitted your completed Consulation form, our offices will be in contact with you.