Power Of Attorney Worksheet printable pdf download

FOR OFFICE USE ONLY

WALK-IN TIME__________ TIME FORM TURNED IN__________ TIME DOCS NOTARIZED__________

ID CARD SCREEN____ __

INTAKE CLERK__________________________________________________________ CMTIS_______ SPOA_______ AFFIDAVIT_______

POWER OF ATTORNEY WORKSHEET

FOR OFFICIAL USE ONLY – PRIVACY ACT SENSITIVE. Any misuse or unauthorized disclosure may result in both civil and criminal penalties.

PRIVACY ACT STATEMENT: AUTHORTY 5 U.S.C. 301 & 44 U.S.C. 3101 DOD ID NUMBER PRINCIPAL PURPOSE(S): Obtain personal information

to prepare legal document(s). ROUTINE USE (S): Information provided will be used by legal assistance personnel (attorneys, legalmen,

paralegals, and clerical staff) to prepare power(s) of attorney requested by the individual providing the information.

MANDATORY/VOLUNTARY DISCLOSURE, CONSEQUENCES OF REFUSAL T O DISCLOSE: Disclosure of DoD ID Number is voluntary and there

will be no adverse consequence from refusal to disclose; however, an individual may be requested to establish eligibility for services by other

means (e.g., production of military identification). Refusal to establish eligibility may preclude the requested assistance. Disclosure of all other

requested information is voluntary, but failure to provide such information may limit this Command’s ability to provide assistance.

Your Name (Last, First, MI):

DoD ID Number (if known):

Date of Birth:

Gender: (circle)

Branch of Service: (circle)

DD_____ MMM____ YYYY_______

USN

USMC

USAF

USCG

USA

DoD

Rank/Rate:

Eligibility:

Office Staff: Reference JAGMAN §0706 for details on Legal Assistance eligibility and consult with your

supervisor on eligibility questions

Home/Cell Phone:

Active Duty

Dependent of Active Duty Member

Retiree

Dependent of Retiree

Work Phone:

Reservist (inactive/drilling)

Dependent of DOD Civilian

(Overseas Only)

20/20/20 Spouse

DOD Contractor

(Overseas Only)

Email:

DOD Civilian

Command:

Your Current Home or Mailing Address:

******READ AND SIGN THE “UNDERSTANDING YOUR POA” FORM ON PAGE 4.******

Please prepare the following legal document(s) for me using the information provided below.

GENERAL FINANCIAL POWER OF ATTORNEY

: BE ADVISED: "General" powers of attorney that have historically been

issued are often rejected by third parties for many transactions. Therefore, we now offer a General Financial Power of Attorney to be used

for basic banking practices (such as paying bills) as well as filing taxes and other routine financial matters.

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

Address: __________________________________________________ Desired expiration date for POA (Limited to one year): __________

SPECIAL POWER(S) OF ATTORNEY (SPOA):

Choose one or more of the SPOAs listed on pages 2 & 3. Please include the

name and contact information for the person receiving the SPOA (your “Agent”) for each SPOA chosen. (You may write “SAME” on

subsequent name, phone and address lines if granting all SPOAs to the same person)

Select ONLY those powers which are applicable to your situation and necessary to conduct your affairs while you are away.

REVOCATION (CANCELLATION) OF POWER OF ATTORNEY

: Please provide the information below.

Name of Person who was granted Power of Attorney:

Type of Power of Attorney granted:

Special

General

Date Power of Attorney was granted:

Type of Special Power of Attorney granted (if applicable):

Account number associated with Power of Attorney (if applicable):

Revised Nov 2014

OJAG Code 16

Mandatory Use

Power Of Attorney Worksheet

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