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Chantelle Custodio – Daily Record’s Medical Malpractice Law Power List 2024
PK Law’s Corporate Transparency Act Update:
Don’t Let Your Claims be Held Captive! Top 10 Considerations When Insurance on Claim is Issued Through a Captive Structure
Federal Judge Blocks FTC’s Ban on Most NonCompete Agreements
PK Law Welcomes Andrew Vernick, Christopher Greaney and Christopher Vernick

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Baltimore, MD

901 Dulaney Valley Road | Suite 500
Towson, MD 21204
P: 410.938.8800 | F: 410.832.5600

Columbia, MD

5950 Symphony Woods | Suite 510
Columbia, MD 21044
P: 410.740.2000 | F: 410.884.7484

Belcamp, MD

4690 Millennium Drive | Suite 200
Belcamp, MD 21017
P: 410.938.8800

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Powers of Attorney Questionnaire

Power of Attorney Questionnaire

Are you seeking a Power of Attorney for yourself?

Yes

No

Are you married?

Yes

No

What is your age?

The person creating/signing the document is called the principle and the person you are designating authority to act to is called the agent. Have you identified the person you would designate as an agent?

Yes

No

Have you identified an alternate agent?

Yes

No

Do you have any question as to the competency of the person you intend to designate as your agent or alternative agent?

Yes

No

Do you have a high level of trust in the person you intend to designate as your agent or alternate agent?

Yes

No

Do you have any concerns about the power of attorney that becomes effective immediately and not when you become incapacitated?

Yes

No

Acknowledgement *

By submitting this form you acknowledge that you have read, understand and agree to the Disclaimer and Terms of Use. You further acknowledge that you understand that your submission of this form in no way creates an attorney client relationship and that such relationship can only be created by written agreement of both parties.

First Name

Last Name

Phone Number

Email

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Elder Law Questionnaire

Elder Law Questionnaire

What is your relationship to the person needing elder care?

Do you have any question as to the competency of the person you are seeking elder care for?

Yes

No

Does the individual have a power of attorney in place?

Yes

No

Where do they currently reside?

Would you like them to continue to reside at this location?

Yes

No

If yes, do they have long term care insurance?

Yes

No

Is there a home or other real estate you would like to protect?

Yes

No

If yes, has the property been transferred within the past five years?

Yes

No

If yes, how and in whose name is the deed titled? (sole ownership, joint tenancy, tenancy in common)

Acknowledgement *

By submitting this form you acknowledge that you have read, understand and agree to the Disclaimer and Terms of Use. You further acknowledge that you understand that your submission of this form in no way creates an attorney client relationship and that such relationship can only be created by written agreement of both parties.

First Name

Last Name

Phone Number

Email

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Health Care Directives Questionnaire

Health Care Directives Questionnaire

Are you seeking a Healthcare Directive for yourself?

Yes

No

Do you already have a Healthcare Directive?

Yes

No

If yes, does it:

Include HIPPA protections?

Name all family members with equal power to make decisions?

Allows the withholding of life support?

Do you have adult children?

Yes

No

If you do not have a spouse or adult children or do not intend to designate any of them as your agent, do you have someone you are close with to designate as your agent?

Yes

No

Is the person you intend to designate as your agent in good health and able to function, including traveling to and from hospital, relatively easily and independently?

Yes

No

Have you considered giving your family members or those you are close to your end of life healthcare wishes?

Yes

No

Acknowledgement *

By submitting this form you acknowledge that you have read, understand and agree to the Disclaimer and Terms of Use. You further acknowledge that you understand that your submission of this form in no way creates an attorney client relationship and that such relationship can only be created by written agreement of both parties.

First Name

Last Name

Phone Number

Email

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Will Questionnaire

Wills Questionnaire

Are you married?

Yes

No

If yes, is this your first marriage?

Yes

No

Do you have children?

Yes

No

What are the ages of your children?

Are any of your children married?

Yes

No

Do you have grandchildren?

Yes

No

Do any of your family members suffer from a disability or have any substance abuse issues?

Yes

No

Do you own real estate?

Yes

No

Is any of the real estate you own located out of Maryland?

Yes

No

Do you own or partially own a business?

Yes

No

Estates are taxable when they exceed $5.5 million. Will you need a plan that takes this into consideration?

Yes

No

Are your assets currently positioned to avoid going through probate?

Yes

No

I don't know

Additional Information

Acknowledgement *

By submitting this form you acknowledge that you have read, understand and agree to the Disclaimer and Terms of Use. You further acknowledge that you understand that your submission of this form in no way creates an attorney client relationship and that such relationship can only be created by written agreement of both parties.

First Name

Last Name

Phone Number

Email

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