March 2010 - PK Law

Powers of Attorney Questionnaire

Power of Attorney Questionnaire

Are you seeking a Power of Attorney for yourself?

Yes

No

Are you married?

Yes

No

What is your age?

The person creating/signing the document is called the principle and the person you are designating authority to act to is called the agent. Have you identified the person you would designate as an agent?

Yes

No

Have you identified an alternate agent?

Yes

No

Do you have any question as to the competency of the person you intend to designate as your agent or alternative agent?

Yes

No

Do you have a high level of trust in the person you intend to designate as your agent or alternate agent?

Yes

No

Do you have any concerns about the power of attorney that becomes effective immediately and not when you become incapacitated?

Yes

No

Acknowledgement *

By submitting this form you acknowledge that you have read, understand and agree to the Disclaimer and Terms of Use. You further acknowledge that you understand that your submission of this form in no way creates an attorney client relationship and that such relationship can only be created by written agreement of both parties.

First Name

Last Name

Phone Number

Email

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If you are human, leave this field blank.

HPK’s Medical Malpractice Defense Group Expands With Addition Of Joan Cerniglia-Lowenson And Kim Longford

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Columbia, MD

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HPK’s Medical Malpractice Defense Group Expands With Addition Of Joan Cerniglia-Lowenson And Kim Longford

Baltimore, MD

Columbia, MD

Belcamp, MD

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