Wyoming Medical Health Care Power of Attorney Form

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Wyoming Medical Health Care Power of Attorney Form

Appoint someone of your choosing to represent your health care interests in the chance you become mentally unstable and cannot make decisions for yourself. This form must be signed by a notary in order to be valid, and simply show up with the form whenever necessary.

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WISCONSIN STATUTORY POWER OF ATTORNEY FOR FINANCES AND PROPERTY IMPORTANT INFORMATION

 

 

This Power of Attorney authorizes another person (your agent) to make decisions concerning your property for you (the principal). Your agent will be able to make decisions and act with respect to your property (including your money) whether

or not you are able to act for yourself. The meaning of authority over subjects listed on this form is explained in the Uniform Power of Attorney for Finances and Property Act in Chapter 244 of the Wisconsin Statutes.

 

This Power of Attorney does not authorize the agent to make health-care decisions for you.

   Recording Area Ç

 

Name and Return Address

You should select someone you trust to serve as your agent. Unless you specify otherwise, generally the agent’s authority will continue until you die or revoke the Power of Attorney or the agent

resigns or is unable to act for you.          Parcel Identification Number (if any)

 

Your agent is entitled to reasonable compensation unless you state otherwise in the special instructions.

 

This form provides for designation of one agent. If you wish to name more than one agent, you may name a co-agent in the special instructions. Co-agents are not required to act together unless you include that requirement in the special instructions.

 

If your agent is unable or unwilling to act for you, your Power of Attorney will end unless you have named a successor agent. You may also name a 2nd successor agent.

 

This Power of Attorney becomes effective immediately unless you state otherwise in the special instructions. This Power of Attorney does not revoke any Power of Attorney executed previously unless you so provide in the special instructions.

 

If you revoke this Power of Attorney, you should notify your agent and any other person to whom you have given a copy. If your agent is your spouse or domestic partner and your marriage is annulled or you are divorced or legally separated or the domestic partnership is terminated after signing this document, the document is invalid.

 

If you have questions about the Power of Attorney or the authority you are granting to your agent, you should seek legal advice before signing this form.

 

DEPARTMENT OF HEALTH SERVICES

Division of Public Health

F-00036 (Rev. 09/10)

 

STATE OF WISCONSIN Effective Date September 1, 2010 s. 244.06 (1), Wisconsin Statutes

 

DESIGNATION OF AGENT

 

I, (name of principal), name the following person as my agent:
Name of agent:
Agent’s address:
Agent’s telephone number:

 

DESIGNATION OF SUCCESSOR AGENT(S) (OPTIONAL)

 

If my agent is unable or unwilling to act for me, I name as my successor agent:

Name of successor agent:                                                                                                                                     Successor agent’s address:                                                                                                                                  Successor agent’s telephone number:

 

 

If my successor agent is unable or unwilling to act for me, I name as my 2nd successor agent:

 

Name of 2nd successor agent:          Second successor agent’s address:

Second successor agent’s telephone number:

 

GRANT OF GENERAL AUTHORITY

 

I grant my agent and any successor agent general authority to act for me with respect to the following subjects as defined (see Appendix) in the Uniform Power of Attorney for Finances and Property Act in chapter 244 of the Wisconsin statutes:

 

(INITIAL each subject you want to include in the agent’s general authority.) Real property

Tangible personal property Stocks and bonds Commodities and options

Banks and other financial institutions Operation of entity or business Insurance and annuities

Estates, trusts, and other beneficial interests

 

Claims and litigation

 

Personal and family maintenance

 

Benefits from governmental programs or civil or military service

 

Retirement plans

 

Taxes

 

LIMITATION ON AGENT’S AUTHORITY

 

An agent who is not my spouse or domestic partner MAY NOT use my property to benefit the agent or a person to whom the agent owes an obligation of support unless I have included that authority in the special instructions.

 

SPECIAL INSTRUCTIONS (OPTIONAL)

 

You may give special instructions in the following space

 

EFFECTIVE DATE

 

This power of attorney is effective immediately unless I have stated otherwise in the special instructions.

 

NOMINATION OF GUARDIAN (OPTIONAL)

 

If it becomes necessary for a court to appoint a guardian of my estate or guardian of my person, I nominate the following person(s) for appointment:

 

Name of nominee for guardian of my estate:                                                                                                         Nominee’s address:                                                                                                                                               Nominee’s telephone number:                                                                                                                               Name of nominee for guardian of my person:                                                                                                        Nominee’s address:                                                                                                                                               Nominee’s telephone number:

 

RELIANCE ON THIS POWER OF ATTORNEY FOR FINANCES AND PROPERTY

 

Any person, including my agent, may rely upon the validity of this power of attorney or a copy of it unless that person knows that the power of attorney has been terminated or is invalid.

 

SIGNATURE AND ACKNOWLEDGMENT

 

Your signature

Date

Your name printed
Your address:
Your telephone number:

 

 

State of:          County of:

 

This document was acknowledged before me on

 

Date                 by name of principal

 

(Seal, if any)

Signature of notary                                                                                                                                                 Name of notary (typed or printed)                                                                                                                          My commission expires:

 

 

This document prepared by:

 

IMPORTANT INFORMATION FOR AGENT

AGENT’S DUTIES

 

When you accept the authority granted under this Power of Attorney, a special legal relationship is created between you and the principal. This relationship imposes upon you legal duties that continue until you resign or the Power of Attorney is terminated or revoked. You must do all the following:

 

(1) Do what you know the principal reasonably expects you to do with the principal’s property or, if you do not know the principal’s expectations, act in the principal’s best interest.

 

(2) Act in good faith.

 

(3) Do nothing beyond the authority granted in this Power of Attorney.

 

(4) Disclose your identity as an agent whenever you act for the principal by writing or printing the name of the principal and signing your own name as “agent” in the following manner:

 

   (principal’s name) by     (your signature) as agent

 

Unless the special instructions in the Power of Attorney state otherwise, you must also do all the following: (1) Act loyally for the principal’s benefit.

(2) Avoid conflicts that would impair your ability to act in the principal’s best interest. (3) Act with care, competence, and diligence.

(4) Keep a record of all receipts, disbursements, and transactions made on behalf of the principal.

 

(5) Cooperate with any person that has authority to make health-care decisions for the principal to do what you know the principal reasonably expects or, if you do not know the principal’s expectations, to act in the principal’s best interest.

 

(6) Attempt to preserve the principal’s estate plan if you know the plan and preserving the plan is consistent with the principal’s best interest.

 

TERMINATION OF AGENT’S AUTHORITY

You must stop acting on behalf of the principal if you learn of any event that terminates this Power of Attorney or your authority under this Power of Attorney. Events that terminate a Power of Attorney or your authority to act under a Power of Attorney include all the following:

 

(1) Death of the principal

 

(2) The principal’s revocation of the Power of Attorney or your authority. (3)  The occurrence of a termination event stated in the Power of Attorney. (4) The purpose of the Power of Attorney is fully accomplished.

(5) If you are married to the principal, a legal action is filed with a court to end your marriage, or for your legal separation, unless the special instructions in this Power of Attorney state that such an action will not terminate your authority.

 

(6) If you are the principal’s domestic partner and your domestic partnership is terminated, unless the special instructions in this Power of Attorney state that such an action will not terminate your authority.

 

LIABILITY OF AGENT

 

The meaning of the authority granted to you is defined in the Uniform Power of Attorney for Finances and Property Act in Chapter 244 of the Wisconsin Statutes. If you violate the Uniform Power of Attorney for Finances and Property Act in Chapter 244 of the Wisconsin Statutes or act outside the authority granted, you may be liable for any damages caused by your violation.

 

If there is anything about this document or your duties that you do not understand, you should seek legal advice.

 

OPTIONAL SIGNATURE OF AGENT

 

I have read and accept the duties and liabilities of the agent as specified in this Power of Attorney.

 

 

 

Agent’s signature              Date

 

 

Attached:

(1) Agent’s certification as to the validity of Power of Attorney for Finances and Property and agent’s authority (Optional).

(2) Appendix: Power of Attorney for Finances and Property Statutory Authority Definitions (Optional).

 

The following optional form may be used by an agent to certify facts concerning a power of attorney for finances and property:

 

AGENT’S CERTIFICATION AS TO THE VALIDITY OF

POWER OF ATTORNEY FOR FINANCES AND PROPERTY AND AGENT’S AUTHORITY

State of:    County of:

 

 

I, (name of agent), certify under penalty of perjury that
                                                                                    (name of principal) granted me authority as an agent or
successor agent in a power of attorney dated

.

 

I further certify that to my knowledge:

 

(1) The principal is alive and has not revoked the power of attorney or my authority to act under the power of attorney, and the power of attorney and my authority to act under the power of attorney have not terminated.

 

(2) If the power of attorney was drafted to become effective upon the happening of an event or contingency, the event or contingency has occurred.

(3) If I was named as a successor agent, the prior agent is no longer able or willing to serve. (4)

(insert other relevant statements)

 

SIGNATURE AND ACKNOWLEDGMENT

 

Agent’s signature

Date

Agent’s name printed
Agent’s address:
Agent’s telephone number:

 

 

State of:          County of:

 

This document was acknowledged before me on

 

Date           by (name of agent)

 

 

(Seal, if any)

 

Signature of notary                                                                                                                                                 Name of notary (typed or printed)                                                                                                                          My commission expires:

 

 

This document prepared by:

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