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FAQ – Estate planning
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Consultation questionnaire – MetLife
Financial power of attorney (POA)
Guardianship and Conservatorship Questionnaire
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Individual pour-over trust
Last will and testament
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Married couple trust package
Medical power of attorney (POA)
Probate Questionnaire
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Medical power of attorney (POA)
Medical Power of Attorney
Complete this form if you are having The Ala Firm prepare a Medical Power of Attorney for you. If you are married, each spouse should complete a separate form/entry.
Your Name
*
First
Middle
Last
Designation of Primary Agent
Do you wish to have your spouse act as your primary agent?
Yes
No
If you are not married, please select “no”.
Provide the full name of your primary agent
First
Middle
Last
Primary agent address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary agent phone
Primary agent email address
Designation of Alternate Agents
Provide the full name of your first alternate agent
First
Middle
Last
First alternate agent address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
First alternate agent phone
First alternate agent email address
Do you wish to identify a second alternate agent in your medical power of attorney?
Yes
No
Provide the full name of your second alternate agent
First
Middle
Last
Second alternate agent address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Second alternate agent phone
Second alternate agent email address
Quality of Life and Comfort Care
Would you like to provide specific instructions for your agent regarding your definition of "quality of life"?
Yes
No
For example, the power of attorney may include language such as: “My agent should bear in mind my standards for maintaining personal dignity and a meaningful quality of life. For me, quality of life requires/involves …”
Provide your definition of "quality of life" or any other standards you wish your agent to consider:
Select one or more of the following statements that describe your wishes
My agent may arrange for my transportation and long term care outside of the state in which I now reside
I do not want to become a burden to my family, or to impose upon them or intrude upon their households
I prefer to receive care in a hospice rather than in a hospital as the end of my life approaches
None of the above
Do you wish to identify certain people or items that you wish to have near you, or to provide that certain things be done for you, to provide additional comfort at the time of your death?
Yes
No
Please describe
Anatomical Gifts (Organ Donation)
You may choose to authorize the donation of your organs, tissue, bone, corneas, and other components of your body. If you desire to add this to your Medical Power of Attorney, please avoid any conflict with the organ donation instructions placed on your drivers’ license.
Do you wish to include instructions for anatomical gifts in your medical power of attorney?
Yes
No
Choose the statement(s) below which best describe your wishes.
My agent can make anatomical gifts on my behalf for the limited purpose of transplantation to such persons and organizations as my agent shall deem appropriate.
My agent can make anatomical gifts on my behalf for the limited purpose of transplantation to members of my immediate family.
My agent can make anatomical gifts on my behalf for use in medical research.
My agent is not authorized to make any anatomical gifts on my behalf.
Unless you select the fourth option, you may choose more than one.
Compensation of Agent
Agents are typically reimbursed for all reasonable expenses, and may be paid for the services rendered while acting as your agent.
Which of the following statements best describes your wishes?
I wish to reimburse reasonable expenses and provide reasonable compensation for services in fact provided by my agent.
I wish to reimburse reasonable expenses incurred by my agent.
I do not wish to reimburse either expenses or compensate for services provided by my agent.
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