Forms > Power of Attorney Form

Power of Attorney Form

A power of attorney form is a legal document. It states that one person usually referred to as the donor or granter has given another person the authority to act on their behalf regarding specific issues. These specific issues include financial affairs, health and personal issues. Below is a sample power of attorney form.

Sample Power of Attorney Form

Please fill in the following gaps.

I ________________ (first name) ________________ (middle name) __________________ (surname) do here by give my consent and permission for ________________ (first name) ________________ (middle name) __________________ (surname) to act on my behalf regarding specific issues. These specific issues are namely:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

I do hereby state that he/ she shall act on my behalf regarding the above states issues for a period of ________________ days ______________ months _______________ years.

The power of attorney shall commence from _________________ up to and only until ________________.

Signature: ___________________________ Date: _________________________

Name of witness: _____________________ Signature: _____________________

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