Short Form Power of Attorney

This is a legal document that can be used in a court of law. You can customize this form to ensure that it clearly shows the role(s) the attorney will oversee on your behalf. It can also be written to take the form of the general obligation law.

Sample Short Form Power of Attorney

Written on this day of _____________ (month, year)

1. I _____________________ (name and address of principal), hereby appoint: ______________ (name and address of agent), as my attorney-in-fact to act for me and on my name and make all decisions for me concerning my personal care, medical treatment, hospitalization and health care and also have the power to withhold or withdraw any type of medical treatment or procedure, even though my death may ensue.
2. The powers given shall not include the following powers ____________________________________________________________________________________________________________________________________

__________________________________________________________________

1. This power of attorney shall become effective as of ________________________________________________________________

__________________________________________________________________

1. This powers shall be terminated on _______________________________________________________

1. In case the attorney dies, the following named persons will take up his place as successor (names given in order of priority).

____________________________________________

___________________________________________

1. I am fully informed of all the contents and power of this form.

Signed _______________________________ (principal)

The principal has had the opportunity to read and understand the full implication of the powers herein stated in my presence ______________________ (witness), residing at ___________

Specimen signature of agent (and successor)

Agent _________________________

Successor _________________________

I certify that the signatures of agent (and successor) are correct.

Principal ___________________________________

Category: Power of Attorney forms