General Power Of Attorney Questionnaire Template (Page 2 of 3) in pdf

Selection of Your Representative (Agent):

I choose the following person to act as my representative to make financial decisions for me. (If married, usually

spouse. If there is an actual disagreement between your agent and your alternate agent, this agent would be

priority.):

Full Legal Name: __________________________________________________________________________________

Address: ________________________________________________________________________________________

City: _________________________________ State: ___________________ ZIP:

________________________

Cell: _______________________________ Work: ________________________ Home: _______________________

I choose the following person to act as my alternate representative to make financial decisions for me. (Optional. If there

is an actual disagreement between your agents, this agent would be secondary.):

Full Legal Name: __________________________________________________________________________________

Address: ________________________________________________________________________________________

City: _________________________________ State: ___________________ ZIP:

________________________

Cell: _______________________________ Work: ________________________ Home: _______________________

Scope and Extent of Powers Granted by the General Power of Attorney (Initial any of the following):

________

Personal Finances: This gives your Agent the ability to withdraw and deposit funds from bank

accounts belonging to you, to enter and remove contents of all safe deposit boxes rented by you,

receive money owed or belonging to you, loan money on your behalf, etc.

________

Real Property: This gives your Agent the ability to purchase real property on your behalf or sell,

lease, subdivide, convey, mortgage, litigate, insure, transfer, encumber, etc. any interest you

have in real property.

________

Personal Property: This gives your Agent the ability to buy personal property on your behalf or

sell, exchange, transfer, litigate, insure, encumber, etc. your personal property.

________

Business Transactions: This gives your Agent the ability to sign and execute any vote, approval,

opposition, termination, investment, disposition, lease, indemnity, agreement, bill of sale, bond,

check, release, etc. on your behalf for any of your business interest/decisions you may have.

________

To Do and Perform Every and All Acts Required: This is the catch all for your Agent to cover all

necessary or appropriate actions which you would do if personally present, and not otherwise

specifically outlined in your General Power of Attorney.

________

Other (Please explain in detail): __________________________________________________

_____________________________________________________________________________

Specific Exclusions You Would Like Contained in the General Power of Attorney (Explain or write “not applicable”):

General Power Of Attorney Questionnaire Template Page 2