Power Of Attorney Worksheet (Page 2 of 4) in pdf

SPECIAL POWER OF ATTORNEY (SPOA) REQUEST FORM

Please choose from options 1 through 12 below to select the power(s) of attorney which are necessary to conduct your affairs while you are away.

1. AUTOMOBILE (See Household Goods (#5) for shipping and Personal Property (#9) for all other Auto matters)

BANKING

Person receiving POA (Last, First, Middle): _________________________________________________________

Address: _______________________________________________________________ Desired expiration date for POA (

): ______________

Limited to one year

Please choose the banking power(s) you wish to grant your agent:

Deposit

Withdrawal (Limited to: $ ______ )

Withdrawal (No Limit)

Withdraw and Deposit (Withdrawal Limits? If so, amount: $______)

Endorse Checks

Obtain Loan (for no more than): $_______________

Obtain Credit Card

Access Safe Deposit Box

Bank Name :

Limits on? # of checks written: _____ Purpose : ____________________________________

Savings Acct # :

Checking Acct #:

3. CHILDREN

CHILD CARE (IN LOCO PARENTIS (specific dates of child care known)) AND/OR

FAMILY CARE PLAN (for a future date when deployed or incapacitated)

Person receiving POA (Last, First, Middle): _________________________________________________________

Address: _______________________________________________________________ Desired expiration date for POA (

): ______________

Limited to one year

Please choose the power(s) you wish to grant your agent (person you are giving permission) with respect to your children:

Medical Appointments

Emergency Medical Care

Dental

Vision

Mental Health Appointments

Enroll in Recreation Activities

Enroll in School

Access to School Records

Access to Medical Records

Provide Food/Shelter

Evacuation

Consent to for Minors to Travel w/in U.S.A.

Consent to for Minors to Travel Outside U.S.A.

(Provide travel destination and passport info for children and

agent below)

Dates of Care:____________________________ Modes of Travel (Car, Plane, etc.): _______________________________

Names(s) of Children

Date of Birth

Passport # & Exp. Date (

(use lines at bottom for more children)

International Travel Only)

1. __________________________________________________________________________________________________________________________

2. __________________________________________________________________________________________________________________________

3. __________________________________________________________________________________________________________________________

Destination (Consent to travel only to the following location(s)): ___________________________ If applicable: Airline: ____________ Flight #: __________

Agent Passport Number/Expiration Date:

Travel Dates (

):_____________________

Consent to travel on these dates only

DEERS/MILITARY AND DEPENDENT ID CARDS/PERSONNEL SUPPORT DETACHMENT MATTERS

Person receiving POA (Last, First, Middle): _________________________________________________________

Address: _______________________________________________________________ Desired expiration date for POA (

): ______________

Limited to one year

*NOTE: This particular POA will allow your agent to obtain an ID Card for you, enroll in DEERS, and generally deal with PSD on your behalf. If not

included in the SPOA, PSD requires DDForm 1172 for enrollment in DEERS when sponsor isn't present.

Expand POA to include dealings with a Public Private Venture (e.g. on-base non-military housing)

HOUSEHOLD GOODS (HHG) INCLUDES AUTO SHIPMENT

Person receiving POA (Last, First, Middle): _________________________________________________________

Address: _______________________________________________________________ Desired expiration date for POA (

): ______________

Limited to one year

Please choose the power(s) you wish to grant to your agent with respect to household goods:

Ship HHG

Ship Property Only

Receive HHG

Ship Auto

Receive Auto

Claim Damages

Execute and Deposit Claim Monies

__________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________________________________

Household Goods/Vehicle Pickup Location

Address of Household Goods/Vehicle Drop-off (if known)

Provide applicable auto info:

Make:________________ Model:______________ VIN#: ________________________________________________

Registration State: _______ Insurance Co/Policy#: _____________________________

Claim $ should be deposited to: Bank Name:____________________________________ Account #: _____________________________

Bank Location (City/State) __________________________________

Revised Nov 2014

OJAG Code 16

Mandatory Use