Power Of Attorney Form - West Virginia (Page 2 of 3) in pdf

Power Of Attorney Form - West Virginia Page 2

[____] 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.

Signature & Acknowledgment

West Virginia

This contract shall be governed by the laws of the State of

in __________ County and any

applicable Federal Law.

__________________________________________________________

Date____________

Signature

By accepting this appointment and acting under it, I the attorney-in-fact (“Agent”) do hereby assume the

legal responsibilities of an agent.

_____________________________________________________________________Date____________

Signature of Attorney-in-Fact

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Power Of Attorney Form - West Virginia Page 2