Power Of Attorney Questionairre

[1] Do you need a power of attorney for financial matters?

Yes No

[2] Do you need a power of attorney for health care matters?

Yes No

[3] Is there an existing power of attorney you need to revoke?

Yes No

[4] Who is giving the power?

[5] Name

[6] Gender

Male Female

[9] In what county and state will this document be signed?

County:

State:

[10] The power of attorney for finances and property matters should be: *

Effective Now Effective Upon Disability "Springing"

Name

Gender

Male Female

Name

Gender

Male Female

Name

Gender

Male Female

[14] If you listed multiple agents above, indicate how they should serve. *

Each agent will serve in the order listed (On the NY form, a third agent cannot be listed with this selection.)
All agents will serve together as co-agents
The first two will serve as co-agents; the third will serve ifeither of the first two is unable (Not available on the NY form.)
The first two will serve as co-agents; the third will serve if both of the first two are unable
The first will serve alone;the second and third will serve as co-agents if the first is unable

[15] If you selected a co-agent option, do they act jointly or separately? * (Not available on the NY form.)

Co-agents must act jointly Co-agents may act separately

Name

Gender

Male Female

Name

Gender

Male Female

Name

Gender

Male Female

[19] If you listed multiple agents, indicates how they should serve. *

Note that co-agents are not an option in the form for the following states: AK, CT, ID, MI, NC, NY, OR, PA, UT

Each agent will serve in the order listed
All agents listed will serve together as co-agents
The first two will serve asco-agents; the third will serve if either of the first two is unable (Not available on the NY form.)
The first two will serve as co-agents;the third will serve if both of the first two are unable
The first will serve alone;the second and third will serve as co-agents if the first is unable

[20] If you selected a co-agent option, do they act jointly or separately? *

Co-agents must act jointly Co-agents may act separately

Customer: The above answers were provided by me and I did not receive any legal advice from We The People personnel in completing my forms.

No part of this document may be reproduced, reused or disclosed without the express written permission of We The People.

We The People

Request For Power of Attorney