Power of Attorney Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.ALL THE INFORMATION YOU PROVIDE IN THIS QUESTIONNAIRE IS STRICTLY CONFIDENTIAL Pennsylvania law gives you the right to direct an agent to control your finances. While you are physically and mentally well enough to personally direct your own finances, you will be in complete charge of the decisions. Once you become unable to understand your financial situation and reach a decision, or communicate the decision to others, a POA will allow you to continue to have control over your finances through your agent. Please keep in mind that no document, no matter how well drafted, is a substitute for thoughtful, informed decision making grounded upon conversations between you and your accountant, your financial advisor, your family, and MOST IMPORTANTLY, between you and your designated POA Agent, BEFORE the loss of capacity Should you have any questions or need clarification do not hesitate to contact our office to discuss your questions, comments, or concerns. PART I – FINANCIAL POWER OF ATTORNEY AGENTS The agent under the Financial Power of Attorney has the power to make decisions on your behalf on a variety of financial-related issues when you are incapacitated. A good agent is honest and loyal, understands your goals and beliefs regarding end-of-life care, does not live far away, and is mentally and physically capable of acting on your behalf when you are unwilling or unable. A secondary agent should be named as a back-up in case the primary agent is unwilling or unable to serve. Designate your primary agent, and at least one alternative agent, Include contact information for each. PRIMARY AGENT: Name *FirstLastRelation to You *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome Phone *Cell Phone *Email *FIRST ALTERNATIVE AGENT Name *FirstLastRelation to You *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome Phone *Cell Phone *Email *SECOND ALTERNATIVE AGENT Name *FirstLastRelation to You *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome Phone *Cell Phone *Email *THIRD ALTERNATIVE AGENT Name *FirstLastRelation to You *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome Phone *Cell Phone *Email *PART II – FINANCIAL AREAS OF AUTHORITY GRANTED Only provide specific account/asset information below when giving specific instructions about how you want a particular account/asset to be handled. When full control is granted, we recommend a separate list of account/asset information be provided which is accessible to your POA Agent prior to, or after the triggering event that causes your incapacity. Banking: do you wish to delegate full control to your agent? *YesNoN/AProvide other specific instructions along with account numbers and name of bank in the space provided. *Safe Deposit Box: do you wish to grant full access to your agent? *YesNoN/AProvide other specific instructions along with box numbers and location of box in the space provided. *Stocks and Bonds: do you wish to delegate full control to your agent? *YesNoN/AProvide other specific instructions along with name of stocks/bonds, amount held and where they are located. *Claims and Litigation: do you wish to delegate full control to your agent? *YesNoN/AProvide other specific instructions. *Lending and Borrowing: do you wish to delegate full control to your agent? *YesNoN/AProvide other specific instructions in the space provided. *Government Benefits: do you wish to delegate full control to your agent? *YesNoN/AProvide other specific instructions in the space provided. *Retirement Plans: do you wish to delegate full control to your agent? *YesNoN/AProvide other specific instructions along with account numbers and location of the account in the space provided. *Taxes: do you wish to delegate full control to your agent? *YesNoProvide other specific instructions along with accountant’s contact info who handled past tax filings in the space provided. *Insurance and Annuities: do you wish to delegate full control to your agent? *YesNoN/AProvide other specific instructions along with policy numbers, policy providers, and names of listed beneficiaries in the space provided. *Estate, Trusts, and other Beneficial Interests: do you wish to delegate full control to your agent? *YesNoN/AProvide other specific instructions that will help us to identify these assets. *Real Estate: do you wish to delegate full control to your agent? *YesNoN/AProvide other specific instructions along with address, ownership share, and names of joint owners in the space provided. *Personal Property: do you wish to delegate full control to your agent? *YesNoProvide other specific instructions along with the name and location of the property in the space provided. *Personal & Family Maintenance: do you wish to delegate full control to your agent? *YesNoN/AProvide other specific instructions along with names of individuals and the standard of living/care to be provided to them in the space provided. *Gifts: do you wish to delegate full control to your agent? *YesNoN/AProvide other specific instructions about any gifts that may be given and to whom they may be given in the space provided. *Liability of Agent: do you wish your agent to be liable to you for actions taken in good faith in execution of their duties under the POA? (imposition of liability could limit the pool of candidates willing to accept this duty) *YesNoReimbursement and Compensation: do you wish for your agent to be reimbursed for reasonable out-of-pocket expenses incurred in execution of his duties under the POA? *YesNoDo you wish for your agent to receive reasonable compensation for execution of their duties under the POA? *YesNoSubmit Call Us 888-357-3197 Address 33 Robinhood DrEtters, PA, 17319-9321, US Send a Message Name Email Address Message Submit
