Lee M. Perlman Durable Power Of Attorney Questionnaire Page 2
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3independent of one another? ☐ Yes ☐ No
NAME OF PROPOSED ALTERNATE OR CO-AGENT
RELATIONSHIP
STREET ADDRESS
CITY
STATE
ZIP CODE
☐ ALTERNATE AGENT
NAME OF PROPOSED
☐ CO-AGENT: Will co-agents be able to make decisions
independent of one another ☐ Yes ☐ No
NAME OF PROPOSED ALTERNATE OR CO-AGENT
RELATIONSHIP
STREET ADDRESS
CITY
STATE
ZIP CODE
PLEASE INDICATE YOUR WISHES BY CHECKING ONE BOX BELOW:
☐
I WANT A GENERAL DURABLE POWER OF ATTORNEY.
THIS TYPE OF POWER OF ATTORNEY GRANTS TO YOUR AGENT BROAD
AUTHORITY AND WILL BECOME EFFECTIVE ON THE DATE THAT YOU SIGN THE
DOCUMENT. THIS POWER OF ATTORNEY WILL REMAIN IN EFFECT
IRRESPECTIVE OF ANY INCAPACITY.
☐
I WANT A SPRINGING DURABLE POWER OF ATTORNEY.
THIS TYPE OF POWER OF ATTORNEY GRANTS TO YOUR AGENT BROAD
AUTHORITY, BUT ONLY BECOMES EFFECTIVE AFTER A DOCTOR HAS CERTIFIED
THAT YOU ARE UNABLE TO MANAGE YOUR AFFAIRS AS A RESULT OF
INCAPACITY.
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