Provide Your Information


Name:Also known as:
Address:
City:    County:
State: Zip:
Phone Number:
Alternate Number:
Email:
Date of Birth:
Social Security Number:

Provide Your Agent's Information (An agent is the person who will act as your power of attorney)

Name:Also known as:
Address:
City:    County:
State: Zip:


Provide Your Alternate Agent's Information

Name:Also known as:
Address:
City:    County:
State: Zip:


Indicate which powers you want to grant to your Agent:

- To buy, sell, mortgage or deal with real estate
- To collect, hold, maintain, improve, invest, lease, or otherwise manage your real or personal property or any interest therein
- To conduct and participate in any kind of lawful business 
- To deposit and withdraw in or from any banking institution, any funds, negotiable paper, or moneys
- To exercise any incidents of ownership you possess with respect to policies of insurance
- To apply to any governmental agency for benefits or government obligations
- To engage in any administrative or legal proceeding or in any litigation in connection with any matter
- To act with respect to any stocks, bonds, shares, or other investments, rights, or interests, including the power to redeem, transfer, or convert United States Savings Bonds
- To engage and dismiss agents, counsel, and employees, and to appoint and remove at pleasure any substitute for your agent
- To prepare, execute, and file income and other tax returns, and other governmental reports and documents
- To transfer any interest you have in property, real or personal, to the trustees of any trust created by you for your benefit
- To have access to your safety deposit box or boxes
- To make, exercise, waive, or consent to any and all elections and/or options regarding your employment benefits 

 ACKNOWLEDGMENT: Speedy Legal Docs did not provide me with any advice, explanation or representation about any legal rights, remedies, defenses or options.