POWER OF ATTORNEY INFORMATION SHEET

 

Personal Information

Name: _________________________________________________________________

Address: _______________________________________________________________

Phone: Alternate Phone: ____________________________________________________

Social Security Number: ____________________________________________________

Date of Birth: ____________________________________________________________

 

Who do you wish to make decisions on your behalf concerning matters such as:

    Real property transactions;

    Tangible personal property transactions;

    Stock bond transactions;

    Commodity and option transactions;

    Banking and other financial institution transactions;

    Business operating transactions;

    Insurance and annuity transactions;

    Estate, trust, and other beneficiary transactions;

    Claims and litigation;

    Personal and family maintenance;

    Benefits from social security, Medicare, Medicaid, or other governmental programs or civil or military service

    Retirement plan transactions;

    Tax matters.

 

1st Choice for Durable Power of Attorney

Name: __________________________________________________________________

Address: _________________________________________________________________

Telephone: _______________________________________________________________

Relationship: ______________________________________________________________

 

2nd Choice for Durable Power of Attorney

Name: ___________________________________________________________________

Address: _________________________________________________________________

Telephone: ________________________________________________________________

Relationship: _______________________________________________________________

 

    Who do you wish to make healthcare decisions on your behalf should you become too ill to make your own healthcare or medical decisions.

 

1st Choice for Healthcare Power of Attorney

Name: ___________________________________________________________________

Address: _________________________________________________________________

Telephone: ________________________________________________________________

Relationship: _______________________________________________________________

 

2nd Choice for Healthcare Power of Attorney

Name: ___________________________________________________________________

Address: _________________________________________________________________

Telephone: ________________________________________________________________

Relationship: _______________________________________________________________

 

After completion, return to:

The Law Offices of

CARROLL & HINOJOSA, PLLC

12702 Toepperwein Road, Suite 140

San Antonio, Texas 78233

Telephone (210) 650-9074

Facsimile (210) 650-3291