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About You
Name
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Address
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Street Address
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Phone
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Marital Status
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About Your Family
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Do you have children?
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Children's Names and Birth Years
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Child's First Name
Child's Last Name
Year of Birth
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Are any of your children under the age of 18?
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Developing
DPOA
AMD
Both
Durable Power of Attorney
When do you want your Power of Attorney to become effective?
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Immediately
Only after I'm incapacitated
Power of Attorney Agent
Choose one and a backup. This person will be responsible for making financial decisions on your behalf when you can't.
Primary Power of Attorney Agent
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First
Last
Backup Power of Attorney Agent
*
First
Last
Primary Guardian for Your Minor Children
*
First
Last
Backup Guardian for Your Minor Children
*
First
Last
Advance Medical Directive (also known as a Health Care Power of Attorney)
Advance Medical Directive Agent
Choose one and a backup. This person will be responsible for making medical decisions on your behalf when you can't.
Do You Want to Donate Your Organs?
*
For Transplantation Only
For Research Only
For Any Purpose
May Not Make Anatomical Gifts
Don't Include This in My AMD
May Your Agent Arrange for Your Psychiatric Treatment?
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Yes
No
Check yes if you allow your Agent to arrange for your voluntary admission for psychiatric treatment upon certification by 2 physicians of need for psychological or substance treatment.
Primary Advance Medical Directive Agent
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First
Last
Backup Advance Medical Directive Agent
*
First
Last
Notes
Is there anything else we should know?
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