LDAs are not lawyers and do not offer legal advice, discuss legal strategies, answer questions of a legal nature, select forms for the consumer, or appear in court on the consumer’s behalf.

Power of Attorney Questionnaire

About you

Your first name *

Use your full legal name, as it appears on your ID.

Your middle name

Your last name *

Address

Home street address *

State *

City *

ZIP code *

Your gender

Male

Female

Used for he/she wording in your documents.

County you live in *

Email *

Cell phone *

Home phone (optional)

Your agent

Your agent: Name, relationship to you, phone, and address *

Your agent is the person who handles your money and property for you.

Do you want a second agent to serve at the same time? *

Yes

Second agent: Name, relationship to you, phone, and address

How should your two agents act?

Together (jointly): both must agree

Separately: either one can act alone

Backup (successor) agent (optional): Name, relationship to you, phone, and address

Steps in if your agent can't or won't serve.

When it starts

When should the power of attorney start? *

Right away

Only if I become unable to manage my affairs

What your agent can do

Which matters can your agent handle for you? (check all that apply) *

Real property (real estate)

Tangible personal property (belongings such as cars and furniture)

Stocks and bonds

Commodities and options

Banking and other financial institutions

Operating a business

Insurance and annuities

Estates, trusts, and other beneficiary matters

Claims and lawsuits

Personal and family maintenance

Government benefits (Social Security, Medicare, Medi-Cal, military or civil service)

Retirement plans

Tax matters

All of the powers listed above

These are the categories on the California Uniform Statutory Form Power of Attorney.

Gifts and pay

Can your agent make gifts of your money or property (for example, birthday or holiday gifts to family)?

Yes

Yes, with limits I'll describe

Describe the limits on gifts

Example: up to $500 per person per year, only to my children

Should your agent be paid for their time?

No, only paid back for expenses

Yes, reasonable pay plus expenses

Not sure yet

Your agent can always be paid back for reasonable expenses.

Special instructions

Special instructions or limits for your agent (optional)

Conservator

If a court ever needs to appoint someone to manage your finances (a conservator), should it be your agent?

Yes

Upload any relevant documents (optional)

PDF, JPEG, JPG, PNG, DOCX or DOC ( max 10 Files )Any existing power of attorney or related documents.

Acknowledgement and Authorization

I understand that the Legal Document Assistant (LDA) preparing my documents is NOT an attorney, cannot select forms and DOES NOT give legal advice. I hereby direct the Legal Document Assistant to type and perform certain services as outlined in the Contract for Services which we each executed regarding this matter. I further declare that the foregoing information which I have provided is, to the best of my knowledge, true and correct.

I have read and agree to the acknowledgment above. *

I agree

Your signature *

Clear

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Santa Clara County Registered LDA #208 | Valid till Sept. 15, 2027

I understand LDAs are not lawyers and do not offer legal advice, discuss legal strategies, answer questions of a legal nature, select forms for the consumer, or appear in court on the consumer's behalf.