Georgia Durable Power Of Attorney Will To Live Form printable pdf download

Georgia Durable Power Of Attorney Will To Live Form

Georgia Durable Power of Attorney

WILL TO LIVE FORM

DURABLE POWER OF ATTORNEY made this _________ day of

_________________, 20____.

I, (your name)__________________________________________________________________

(your address)__________________________________________________________________

_____________________________________________________________________________

(your phone number)____________________________________________________________

hereby appoint:

(Name of agent)________________________________________________________________

(address of agent)_______________________________________________________________

(phone number(s) of agent)_______________________________________________________

as my attorney-in-fact (my agent) to act for me and in my name in any way I could act in person

to make any and all decisions for me concerning my health care and to consent to health care in

accordance with the following instructions. My agent shall have the same access to my medical

records that I have, including the right to disclose the contents to others.

If any agent named by me shall die, become legally disabled, incapacitated, or

incompetent, or resign, refuse to act, or be unavailable, I name the following (each to act

successively in the order named) as successors to such agent:

1.____________________________________________________________________________

______________________________________________________________________________

(first successor’s name, address, and telephone number)

2.____________________________________________________________________________

______________________________________________________________________________

(second successor’s name address, and telephone number)

(The following paragraph is OPTIONAL. If you do not want to nominate a guardian, CROSS

OFF the blank lines and initial your cross-off.)

If a guardian of my person is to be appointed, I nominate the following to serve as my guardian:

(nominated guardian’s name, address, and phone number_______________________________

______________________________________________________________________________

Page 1 of 5

Georgia Durable Power Of Attorney Will To Live Form