onlinepoa – Guam Elder Justice Center

Durable Power of Attorney Questionnaire

- Step 1 of 9

Please tell us some information about you.

This section should be information about yourself.

Your Full Name *

First

Middle

Last

Your Date of Birth *

Your Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Your Phone *

Your Email *

Person whom you will grant power to

Please complete this section with the information of the person your wish you be your Agent.

Agent's Full Name *

First

Middle

Last

Agent's Date of Birth *

Agent's Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Agent's Phone

Agent's Email

Alternate person whom you will grant power to

This section is optional. You may provide an additional person, just in case, or you can skip this section by clicking NEXT.

Alternate's Full Name

First

Middle

Last

Alternate's Date of Birth

Alternate's Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Alternate's Phone

Alternate's Email

Agent Powers

In this section you will decide what powers you would like to give your Agent.

Please CHECK the box for the powers you will be giving to your Agent.

BANKING: To receive, deposit, and withdraw funds.
PAY BILLS: To pay any bills, accounts, claims, and demands now or hereafter owed by principal.
COLLECT: To collect and receive any monies which are now or which may become due, owing, and payable to the principal.
SAFE DEPOSIT BOX: To have access at any time or times to any safe deposit box rented by me or to which I may have access.
LENDING OR BORROWING: To make loans in my name; to borrow money or mortgage property in my name in my name.
GOVERNMENT BENEFITS: To apply for and receive any government benefits for which I may be eligible or become eligible, including but not limited to, Social Security, Medicare and Medicaid.
RETIREMENT PLAN: To contribute to, select payment option of, roll-over, and receive benefits of any retirement plan or IRA I may own, except my attorney-in-fact shall not have power to change the beneficiary of any of my retirement plans or IRAs.
TAXES: To complete and sign and pay any local, state and federal tax returns on my behalf.
INSURANCE: To purchase insurance on my behalf, except my attorney-in-fact shall not have the power to cash in or change the beneficiary of any life insurance policy.
PERSONAL PROPERTY: To purchase and sell my personal property.
POWER TO MANAGE PROPERTY: To manage my property.
LEGAL ADVICE AND PROCEEDINGS: To obtain and pay for legal advice including actions against third parties who refuse, without cause, to honor this instrument.
UTILITIES: To apply for and/or terminate power, water, telephone, cable, and any other utilities in the principal's name.
MEDICAL/DENTAL: To schedule doctor’ and dental appointments and to authorize all medical, dental, and hospital care and treatment and to execute all such consents, authorizations, and releases.
PUBLIC BENEFITS: To apply and get re-certification of public benefits.
SOCIAL SECURITY: To deal with Social Security Administration.

Please specify Name of Bank(s) and Account Number(s) below: *

(example: Bank of Yona, Checking Account #02-123456)

Would you like to grant your agent Powers concerning your Healthcare? *

You have selected HEALTHCARE as one of the powers you will grant to your Agent. Please select those powers from the following: *

To agree to, refuse, or withdraw consent to any type of medical care, treatment, surgical procedures, tests, or medications. This includes decisions about using mechanical or other procedures that affect any bodily function, such as artificial respiration, cardiopulmonary resuscitation, or other forms of medical support, even if deciding to stop or withhold treatment could or would result in my death.
To request that a physician responsible for my care issue a do-not-resuscitate (DNR) order, including an outof- hospital DNR order, and sign any required documents and consents.
To have access to medical records and information to the same extent that I am entitled to, including the right to disclose health information to others.
To authorize my admission to or discharge (even against medical advice) from any hospital, nursing home, residential care, assisted-living or similar facility or service.
To contract for any health care-related service or facility for me, or apply for public or private health care benefits, with the understanding that my agent is not personally financially responsible for those contracts.
To hire and fire medical, social service, and other support personnel who are responsible for my care.
To authorize my participation in medical research related to my medical condition.
To decide about organ and tissue donations, autopsy, and the disposition of my remains as the law permits.
To take any other action necessary to do what I authorize here, including signing waivers or other documents, pursuing any dispute resolution process, or taking legal action in my name.

Do you have and Advance Directive? *

Not Sure
I previously executed a Living Will or other Advance Directive for medical care. (THIS DOES NOT TAKE THE PLACE OF MY LIVING WILL. Should there be a conflict between this Directive and my Living Will, my Living Will controls. )
I do not have any previous advance directives. (This will be the first advance health directive I make. I do not have a Living Will. My Health Care Agent will make all decisions.)

Other Information

This power of attorney shall not be affected by the disability of the principal *

This power of attorney shall become effective upon the disability or incapacity of the principal *

Do you want this POA to expire within a certain period of time? *

When would you like the POA to expire?

Remember, your POA terminates upon your death.

Special Instructions

On the following lines are any special instructions limiting or extending the powers I give to my attorney-in-fact (Write “None” if no additional instructions are to be given) *

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You are almost ready to submit your information to the Elder Justice Center.

Please read and select the option below to submit this form. *

I agree to be contacted by a representative of the Guam Elder Justice Center at the contact information I provided in this form.

Durable Power of Attorney Questionnaire

Please tell us some information about you.

Person whom you will grant power to

Alternate person whom you will grant power to

Agent Powers

Other Information

***Remember, your POA terminates upon your death.***

Special Instructions

You are almost ready to submit your information to the Elder Justice Center.

Remember, your POA terminates upon your death.