Insert date, use calendar to the right if necessary.
When do you want this to go into effect?
Name of the person preparing the Power of Attorney, type your entire address, city, state, zip on one line, and include your area code and phone number.
Use the drop down box to select the your state.
Type the name of the County where you reside.
Name of the person that you wish to make decisions if your are unable.
Include the complete address, city, state, zip on one line and their phone number.
Second choice to act for you if the Primary Decision Maker is unavailable?
Third choice to act for you if the Primary and First Alternates are unavailable?
Alternates are not mandatory, however it is wise to have at least one as a backup.
