Power Of Attorney Application printable pdf download

Power Of Attorney Application

POWER OF ATTORNEY APPLICATION

LSSS-NCR Quantico Legal Assistance Office

PRIVACY ACT STATEMENT: Information is solicited in accordance with Title 10, US Code Section 3013, and is used to provide

information necessary in preparation of a Power of Attorney. Solicited information is voluntary; however, failure to provide

information precludes the preparation of a power of attorney.

YOUR NAME (First, MI, Last)

RANK / Branch of Service:

LAST 4 OF SSN:

POA EXPIRATION DATE:

(MAX – 1 year)

Active Duty

______

Family Member ______

Retired

______

Have you previously visited our office and received any type of service:

Yes

If you are a service member, do you want this POA to remain in effect if you become a prisoner of war or are

declared missing?

State of Legal Residence:

Duty Station:

NAME OF PERSON RECEIVING POA (Your agent):

Complete Address:

1.  GENERAL Power of Attorney

TYPE OF POWER OF

2.  SPECIAL Power of Attorney (Check as many of a-g below as you

ATTORNEY: (check one)

need)

NOTE: If you are requesting a General Power of Attorney, you do not need to complete the

remainder of this form. However, if you request a Special Power of Attorney, please check

the categories that apply and provide the requested information.

 Cash checks, etc.

 File claims/receive

 Obtain Service

a Claims/Financial Transactions:

(Check w/your bank)

payments

Relief Loan

 Sign for

 Clear

b. Government Quarters:

Location of Quarters:

 Receive

 Ship

c. Household goods/personal property:

d. Real Property:

 Buy/Mortgage

 Refinance

 Sell

 Manage



 Lease your current house

 Lease new property

Complete Address of Property:

e. Vehicles:  Possess, use, register, etc.

 Sell

 Buy

 Ship

 Receive

Year/Make/Model of vehicle: _______________________________________

Vehicle Identification Number: ______________________________________

 Medical only

 Guardianship

f. Child Care:

Child(ren)’s full name(s) and date(s) of birth:

g.  Other: (Insert Description)

Power Of Attorney Application

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