LPA

LASTING POWER OF ATTORNEY QUESTIONNAIRE
Which LPA do you want Property and Finance, Health and Welfare or Both? *We strongly recommend having both LPAs unless you already have a different power of attorney in place
- Property and Finance
- Health and Welfare
- Both
DONOR
Donor's Full Name
First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Known by any other names
Date of Birth
DD slash MM slash YYYY
Phone

ATTORNEYS We would recommend you appoint at least two attorneys:-
1st Attorney Full Name
First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
DD slash MM slash YYYY
Phone
Occupation
Relation to Donor
2nd Attorney Full Name
First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
DD slash MM slash YYYY
Phone
Occupation
Relation to Donor
3rd Attorney Full Name
First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
DD slash MM slash YYYY
Phone
Occupation
Relation to Donor
4th Attorney Full Name
First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
DD slash MM slash YYYY
Phone
Occupation
Relation to Donor

REPLACEMENT ATTORNEY The Replacement Attorneys will only be able to act if the original Attorney cannot act.
1st Replacement Attorney's full name
First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
DD slash MM slash YYYY
Phone
Relation to Donor
2nd Replacement Attorney's full name
First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
DD slash MM slash YYYY
Phone
Relation to Donor