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Estate Planning Durable Power of Attorney Worksheet

A power of attorney (POA) is a written instrument that allows you (the “grantor”) to authorize another person or institution (your

“agent” or “attorney-in-fact”) to conduct certain business for you. It is one of the most powerful legal documents that you can give to

another person. There are two types of POA; “general” or “special” (or limited).

A general POA gives your agent very broad powers to act on your behalf. Every act performed by your agent within the

authority of the POA is legally binding upon you. Since a POA is such a powerful document, give it only to a trustworthy person, limit

the authority you grant whenever possible, and only give a power of attorney when absolutely necessary.

Making a General Power of Attorney (GPOA) is an important action with serious consequences. Your GPOA gives someone

else the legal authority to act on your behalf--to do anything that you could do. With a GPOA, your agent can (for example) rent or buy

a house with your money, borrow money that you must repay, sell your car or buy a car, sue someone for you, or remove all funds from

your bank account. Your agent can legally bind you. While a GPOA can be very helpful, it can also be very dangerous.

A GPOA will not allow the agent to consent for medical/dental treatment for a child or medical treatment for you. It is up to the

merchant or business where the power of attorney is presented to accept it. If you know of a specific reason you may need someone to use the power of attorney, check with that merchant/business first to see what type, if any, power of attorney they will accept.

______________________________________________

Amanda Salcido, CPT, JA, Chief, Client Services

I have read the information above concerning a general power of attorney and understand that the power of my agent is very

broad. I understand that I will be liable for any actions taken by my agent while this power of attorney is valid.

I understand that this worksheet (NOT a copy of the power of attorney) will be retained in the III Corps Legal Assistance Office (or

transferred to the Records Holding Area) for a minimum of three years from today’s date.

________________________________ _____________________________________________

Date Signature

1. Marital Status Married Single Widowed Divorced Separated or about to divorce

3. Name (First, Middle, Last) Your Soc. Sec. No.

4. Home Address (Number, Street, City, State, zip code)

5. Home Phone Work Phone Cell Phone

( ) ( ) ( )

7. State of Legal Residence (where you vote and pay taxes) :

8. First Agent:

Full Name (First, Middle, Last)

Address

Phone Number: Home: ( ) Work: ( ) Cell: ( )

Relationship

9. Second Agent (Initial to right if second agent not desired) NO Alternate ________

Full Name (First, Middle, Last)

Address

Phone Number Home: ( ) Work: ( ) Cell: ( )

Relationship

10. If you have named an second agent, in what order do you want your agent(s) to act (select YES on only ONE):

Agents are to act in order as shown (primary and alternate). Yes No

Agents must act together (unless one is incapacitated). Yes No

Agents may both act, and act separately from one another. Yes No

This power of attorney shall: _____ ** Survive if I become incompetent or disabled (durable power of attorney)

_____ Become effective only if I become incompetent or disabled (springing power of

attorney)

_____ Be silent as to incompetency or disability

Expiration date:

______ ** Shall terminate upon my death

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______ Shall terminate on this date: ________________________________

I want my agent to be able to do the following:

______ All of the acts shown on the standard GPOA (indicated with an ** below)

** Sell a business I own

** Sell real estate

** Make gift of cash and/or property that is limited to amount excludable under Internal Revenue Code

** Can disclaim bequests or transfers made to me

** Can make changes to my retirement plan and/or IRAs

** Income tax matters, including paying income tax, filing tax returns, and other tax matters that may arise

** If a guardian of my person is necessary, it is my desire that my agent be appointed as my guardian

** The GPOA shall be silent as to compensation of my agent.

= = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = =

If you desire any of the additional/alternate clauses below, please select them by initialing in front of the line. It will

take a little longer to prepare your document if you select additional/alternate clauses, but we will prepare the

document to suit your needs.

I want my agent to be able to do the acts I have selected below:

______ Sell a specific parcel of real estate (provide address including city, county, state) ___________________

__________________________________________________________________________________

______ Make gift of cash and/or property that may exceed the IRS limit if the gift will be used for tuition and fees for

higher education or medical expenses

______ Attorney-in-fact (agent) may make gifts to self (select only one): ______ No;

______ Yes, but limited to $5,000 or 5% of my property; ______ No limit to gift

______ Make transactions involving an inter vivos (living) trust (available only if you currently have a living trust)

______ Can revoke or amend trust; ______ Can transfer property to existing trust; and/or

______ Can create an inter vivos trust

Prior General Powers of Attorney:

______ State that all other General Powers of Attorney executed by me before this date are revoked by this

document

Compensation of Attorney-in-fact (select one):

______ My agent is entitled to reasonable compensation OR ______ My agent is not to be compensated

Miscellaneous:

______ My agent will not be liable for any acts taken when using this GPOA except those involving willful

misconduct or gross negligence

______ My agent shall be required to give me periodic reports on matters addressed with the GPOA -

These reports will be provided to me: ______ Quarterly ______ Annually ______ Monthly