DURABLE POWER OF ATTORNEY AND HEALTHCARE DIRECTIVE QUESTIONNAIRE

(Skip this section if you have already completed a Will/Trust Questionnaire)

PERSONAL INFORMATION SECTION

Your Personal Information:

Address

Street Address

City

State

Country

Postal code

Full Name *

Email *

S.S. #: *

Date of birth *

Gender *

Male

Female

Your Spouse’s Personal Information (if applicable):

Your Spouse Name *

Your Spouse Address *

Your Spouse Phone Number *

Your Spouse Date of Birth *

Your Spouse S.S. #: *

Your Spouse Gender *

Male

Female

DURABLE POWER OF ATTORNEY

Effective date of your Power of Attorney: *

Only when incapacitated

Immediately

My incapacity shall be determined by: *

One doctor chosen by my attorney-in-fact
One doctor I name:
Two doctors chosen by my attorney-in-fact
Two doctors I name:

Attorney-in-Fact Selection: *

1 person

2 person

3 person

Co-Agents

Attorney-in-Fact (1):

Name:
Address:
Telephone:

Attorney-in-Fact (2) (Optional Alternate for #1 or Co-Agent):

Name:
Address:
Telephone:

Attorney-in-Fact (3) (Optional Alternate for #2 or Co-Agent):

Name:
Address:
Telephone:

If you are appointing co-agents, please describe how they should serve:

Do you require your attorney-in-fact to make periodic reports?

Yes

No

Yes (If yes, specify who should receive the reports):

HEALTHCARE DIRECTIVE

If you are diagnosed as having a terminal condition and can no longer direct your medical care, select one: *

I do not want any life-prolonging procedure

DO / DO NOT want food and water artificially administered

DO / DO NOT want all pain reduction and/or comfort care

I desire the following representative to oversee my wishes: *

Attorney-in-Fact #1
Attorney-in-Fact #2
Attorney-in-Fact #3

I desire the following representative to act as an alternate:

Attorney-in-Fact

FEMALES ONLY:

If I am pregnant when my healthcare directive is considered:

I direct it be given no effect during my pregnancy

I direct that it be carried out

ACKNOWLEDGMENT 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.

Enter Date Here *

Enter Signature here *

Clear

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