Power of Attorney Form for Medical and Financial

DURABLE POWER OF ATTORNEY FOR FINANCIAL AFFAIRS AND ADVANCE HEALTH CARE DIRECTIVE

DOCUMENT CONTROL INFORMATION Document ID: DPOA-HC-2024-V1.0 Effective Date: [Effective Date] Version: 1.0 (Standardized Institutional Form) Governing Jurisdiction: [State/Province/Territory] Principal: [Principal Full Legal Name] Attorney-in-Fact/Agent: [Agent Full Legal Name]

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STATUTORY & LEGAL COMPLIANCE NOTICE

NOTICE TO THE PRINCIPAL: THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD AND SWEEPING. THEY ARE EXPLAINED IN THE UNIFORM POWER OF ATTORNEY ACT OR THE CORRESPONDING STATUTES OF THE GOVERNING JURISDICTION. THIS DOCUMENT ALLOWS THE APPOINTED AGENT TO MANAGE YOUR PROPERTY AND MAKE MEDICAL DECISIONS ON YOUR BEHALF. THESE POWERS WILL EXIST EVEN AFTER YOU BECOME INCAPACITATED. YOU HAVE THE RIGHT TO REVOKE THIS POWER OF ATTORNEY AT ANY TIME WHILE YOU ARE COMPETENT.

NOTICE TO THE AGENT: BY ACCEPTING OR ACTING UNDER THIS APPOINTMENT, YOU ASSUME THE FIDUCIARY DUTY AND LEGAL RESPONSIBILITIES OF AN AGENT. YOU MUST ACT IN ACCORDANCE WITH THE PRINCIPAL’S REASONABLE EXPECTATIONS TO THE EXTENT ACTUALLY KNOWN BY YOU AND, OTHERWISE, IN THE PRINCIPAL’S BEST INTEREST.

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1. PARTIES & RECITALS

1.1 THE PRINCIPAL. I, [Principal Full Legal Name], residing at [Principal Full Address] (the "Principal"), being of sound mind and acting of my own free will, hereby appoint the following person to act as my Attorney-in-Fact and Agent (the "Agent"):

1.2 THE AGENT. [Agent Full Legal Name], residing at [Agent Full Address].

1.3 SUCCESSOR AGENT (Optional). In the event the Agent is unable or unwilling to serve, I appoint [Successor Agent Full Legal Name], residing at [Successor Agent Full Address] (the "Successor Agent").

1.4 RECITALS. The Principal desires to create a comprehensive legal framework whereby the Agent may manage the Principal’s financial affairs and healthcare decisions. This instrument is intended to function as a Durable Power of Attorney for Financial Affairs and a Health Care Proxy/Advance Directive.

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2. EXHAUSTIVE OPERATIVE CLAUSES: FINANCIAL POWERS

2.1 SCOPE OF FINANCIAL AUTHORITY. I grant my Agent the full power and authority to manage my financial affairs as if I were personally present and acting. This includes, but is not limited to:

• Real Property: To buy, sell, mortgage, lease, and manage any real estate I own or may acquire.
• Banking and Financial Institutions: To open, close, and maintain accounts; to withdraw and deposit funds; and to access safe deposit boxes.
• Stocks and Securities: To buy, sell, and vote proxies for stocks, bonds, and other investments.
• Operation of Business: To manage any business interest I own, including making capital contributions or dissolving the entity.
• Insurance and Annuities: To pay premiums, surrender policies, or change beneficiaries (subject to applicable law).
• Tax Matters: To prepare, sign, and file all tax returns (IRS Form 2848 or equivalent) and represent me before any taxing authority.

2.2 COMPENSATION & PAYMENT TERMS. The Agent shall be entitled to reimbursement for all reasonable and documented out-of-pocket expenses incurred in the performance of their duties under this Agreement. The Agent [Select One: SHALL / SHALL NOT] be entitled to reasonable compensation for services rendered, calculated at a rate of [Amount in USD] per hour, not to exceed [Amount in USD] per calendar month without prior judicial or trust-based approval. All invoices for services must be documented and maintained for the Principal’s audit.

2.3 INTELLECTUAL PROPERTY OWNERSHIP & WORK MADE FOR HIRE. To the extent the Agent creates, develops, or authors any works, processes, or intellectual property while acting on behalf of the Principal or using the Principal’s assets, such works shall be considered "Work Made for Hire" under the Copyright Act (17 U.S.C. § 101 et seq.) or applicable local law. All rights, title, and interest in such property shall vest exclusively in the Principal. The Agent hereby irrevocably assigns all such rights to the Principal in perpetuity.

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3. EXHAUSTIVE OPERATIVE CLAUSES: MEDICAL POWERS

3.1 SCOPE OF MEDICAL AUTHORITY (HEALTH CARE PROXY). I grant my Agent the authority to make any and all health care decisions for me if I am unable to do so myself, including:

• Access to Information: Full authority to request, receive, and review any information regarding my physical or mental health, including all HIPAA-protected records.
• Informed Consent: To grant, refuse, or withdraw consent for any medical procedure, treatment, or pharmaceutical intervention.
• Placement: To authorize my admission to or discharge from any hospital, nursing home, or residential care facility.

3.2 END-OF-LIFE DIRECTIVES. If I am in an incurable or irreversible mental or physical condition with no reasonable expectation of recovery, I direct my Agent to [Select One: WITHHOLD / PROVIDE] life-sustaining treatment, including artificial nutrition and hydration, in accordance with my wishes as previously expressed to the Agent.

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4. LEGAL TERMS & DISCLOSURES

4.1 DURABILITY. This Power of Attorney shall not be affected by my subsequent disability or incapacity. All acts done by my Agent during any period of my incapacity shall have the same effect and inure to the benefit of and bind me and my successors in interest as if I were competent.

4.2 TERM & TERMINATION.

• Convenience: This Agreement remains in effect until the death of the Principal or until written revocation is delivered to the Agent and recorded (if applicable).
• Breach: If the Agent breaches any fiduciary duty, this Agreement may be terminated immediately by the Principal or a court of competent jurisdiction.
• Cure Period: In the event of a non-material administrative breach, the Agent shall have [Number] days to cure the breach after written notice.

4.3 MUTUAL CONFIDENTIALITY & NON-DISCLOSURE. The Agent shall maintain the absolute confidentiality of the Principal’s medical, financial, and personal information. Disclosure is permitted only when required to execute the duties herein, by court order, or to authorized legal and tax professionals.

4.4 REPRESENTATIONS & WARRANTIES. The Principal warrants that they possess the requisite capacity to execute this instrument. The Agent, by signing or acting hereunder, warrants that they are not subject to any legal disability or conflict of interest that would prevent the ethical execution of these duties.

4.5 LIMITATION OF LIABILITY & INDEMNIFICATION. The Agent shall not be liable to the Principal or the Principal’s successors for any error of judgment or mistake of law, except in cases of willful misconduct or gross negligence. The Principal’s estate shall indemnify and hold the Agent harmless from any liability incurred while acting in good faith within the scope of this Agreement.

4.6 DISPUTE RESOLUTION & ARBITRATION. Any dispute arising out of or relating to this Agreement shall be settled by binding arbitration in [City, State] in accordance with the Commercial Arbitration Rules of the American Arbitration Association. Judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof.

4.7 GOVERNING LAW & JURISDICTION. This document shall be governed by, and construed in accordance with, the laws of the State of [Governing Jurisdiction], without regard to conflict of law principles.

4.8 MISCELLANEOUS.

• Severability: If any provision is held invalid, the remainder shall continue in full force.
• Counterparts: This document may be executed in counterparts and via electronic signature (e.g., DocuSign).
• Entire Agreement: This constitutes the entire agreement between the parties regarding the subject matter herein.

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5. EXECUTION & FORMAL SIGNATURE BLOCKS

IN WITNESS WHEREOF, the Principal and Agent have executed this Document as of the Effective Date first written above.

PRINCIPAL'S SIGNATURE: Signature: _____________________________________ Printed Name: [Principal Full Legal Name] Date: [Date]

FOR THE AGENT: Signature: _____________________________________ Printed Name: [Agent Full Legal Name] Title: Attorney-in-Fact / Agent Date: [Date]

FOR THE SUCCESSOR AGENT (Acceptance of Contingent Appointment): Signature: _____________________________________ Printed Name: [Successor Agent Full Legal Name] Title: Successor Attorney-in-Fact Date: [Date]

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6. WITNESS & NOTARY ACKNOWLEDGMENT

WITNESS ATTESTATION I, the witness, declare that the Principal signed this document in my presence and appeared to be of sound mind and under no duress.

Witness 1 Signature: ___________________________ Name: [Witness 1 Name] Witness 2 Signature: ___________________________ Name: [Witness 2 Name]

NOTARY ACKNOWLEDGMENT STATE OF [State] COUNTY OF [County]

On this [Day] of [Month], [Year], before me personally appeared [Principal Full Legal Name], known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that he/she executed the same for the purposes therein contained.

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NOTARY PUBLIC My Commission Expires: [Date]

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STEP-BY-STEP EXECUTION & FILING GUIDE

1. Variable Completion: Open this document in Microsoft Word or Google Docs. Use the "Find and Replace" function to locate all bracketed terms (e.g., [Principal Full Legal Name]) and replace them with the actual legal identities and addresses of the parties.
2. Verify Authority: Ensure the Principal is of sound mind at the time of signing. If capacity is in question, obtain a letter from a licensed physician.
3. Digital/Physical Execution:
   • Physical: Print three (3) copies. Use blue ink for original signatures to distinguish from photocopies.
   • Digital: If using DocuSign or Adobe Sign, ensure the platform provides a "Certificate of Completion" that logs IP addresses and timestamps. Note: Many jurisdictions still require physical notarization for Real Estate-related POAs.
4. Notarization: This document must be signed in the presence of a Notary Public. The Notary should apply their seal to the Notary Acknowledgment section.
5. Witnessing: Most jurisdictions require two disinterested witnesses (not the Agent, not a relative, and not a beneficiary of the estate).
6. Filing & Record Retention:
   • Provide a copy to the Agent and Successor Agent.
   • Provide a copy to the Principal’s primary care physician and hospital system.
   • Provide a copy to the Principal’s primary banking institution.
   • Keep the original in a fireproof safe or with the Principal’s legal counsel.