MM slash DD slash YYYY
Power of Attorney Effective Date
- Located at
- Located at
- As my attorney-in-fact.
My attorney-in-fact may act on my behalf for the following purpose(s): (INITIAL)
Real Estate Transactions
Stock and Bond Transactions
Commodity and Option Transactions
Tangible Personal Property Transactions
Banking and Other Financial Institution Transactions
Business Operating Transactions
Insurance and Annuity Transactions
Estate, Trust and Other Beneficiary Transactions
Claims and Litigation
Personal and Family Maintenance
Benefits from Social Security, Medicare, Medicaid or Other Government Programs
Retirement Plan Transactions
Tax Matters, including any transactions with the Internal Revenue Service
Decisions Regarding Lifesaving and Life Prolonging Medical Treatment.
Decisions Relating to Medical Treatment, Surgical Treatment, Nursing Care, Medication,
Hospitalization, Institutionalization in a nursing home or other facility and home health care
Transfer of Property or Income as a Gift to the Principal’s Spouse for the purpose of
qualifying the principal for governmental medical assistance.
All OF THE ABOVE POWERS, INCLUDING FINANCIAL AND HEALTH CARE DECISIONS. This
power of attorney shall take effect on the above mentioned effective date and will continue
indefinitely or until revoked by me or by my death.
I do hereby grant my attorney in fact complete authority to act in any reasonable manner that
is necessary to execute the above mentioned powers that are granted.
I agree that any third party who is given a copy of this power of attorney may act relying on it. I
also agree that revocation of this power of attorney is effective as to a third party only upon
receipt of actual notice by the third party. I agree to indemnify the third party for any loss that
may be suffered while carrying out this power of attorney.