Power of Attorney Form - Your Security. Your peace of mind.

Section C:
Durable Power of Attorney for Health Care
In the event you become incapacitated, the person(s) you have chosen as Power of Attorney, or “Attorney in Fact,” is to act on your behalf in making health care decisions for you. Your spouse would ordinarily be named as Primary Agent.
The Agent(s) named*
- The Agent(s) named are to serve in order listed
- The Agent(s) named are to serve together (jointly)
- Power of Attorney for Client 1:
- Durable POA Health Client 1 Spouse
  - Spouse or:
- Name
- Phone
- Name
- Phone
- Name
- Phone
- Remains
  - Cremation
  - Burial
- Power of Attorney for Client 2:
- Spouse
  - Spouse or:
- Name
- Phone
- Name
- Phone
- Name
- Phone
- Remains
  - Cremation
  - Burial

ACKNOWLEDGMENT: I/We have read the information on this application and confirm that it is true and correct.
- Client 1 Signature*
- Date*
- Client 2 Signature
- Date
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

Section A:
Client Personal Information