"Power of Attorney Form" - Indiana

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Download "Power of Attorney Form" - Indiana

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Indiana Power of Attorney
I ___________________________________________________________(name and address)
appoint:
____________________________________________________________(name and address)
As my agent (attorney-in-fact) to act for me in any lawful way with respect to the following
initialed subjects:
[____] Real Estate Transactions
[____] Stock and Bond Transactions
[____] Commodity and Option Transactions
[____] Tangible Personal Property Transactions
[____] Banking and Other Financial Institution Transactions
[____] Business Operating Transactions
[____] Insurance and Annuity Transactions
[____] Estate, Trust and Other Beneficiary Transactions
[____] Claims and Litigation
[____] Personal and Family Maintenance
[____] Benefits from Social Security, Medicare, Medicaid or Other Government Programs
[____] Retirement Plan Transactions
[____] Tax Matters, including any transactions with the Internal Revenue Service
[____] Decisions Regarding Lifesaving and Life Prolonging Medical Treatment.
[____] Decisions Relating to Medical Treatment, Surgical Treatment, Nursing Care, Medication,
Hospitalization, Institutionalization in a nursing home or other facility and home health care.
[____] Transfer of Property or Income as a Gift to the Principal’s Spouse for the purpose of
qualifying the principal for governmental medical assistance.
[____] All OF THE ABOVE POWERS, INCLUDING FINANCIAL AND HEALTH CARE DECISIONS.
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Indiana Power of Attorney
I ___________________________________________________________(name and address)
appoint:
____________________________________________________________(name and address)
As my agent (attorney-in-fact) to act for me in any lawful way with respect to the following
initialed subjects:
[____] Real Estate Transactions
[____] Stock and Bond Transactions
[____] Commodity and Option Transactions
[____] Tangible Personal Property Transactions
[____] Banking and Other Financial Institution Transactions
[____] Business Operating Transactions
[____] Insurance and Annuity Transactions
[____] Estate, Trust and Other Beneficiary Transactions
[____] Claims and Litigation
[____] Personal and Family Maintenance
[____] Benefits from Social Security, Medicare, Medicaid or Other Government Programs
[____] Retirement Plan Transactions
[____] Tax Matters, including any transactions with the Internal Revenue Service
[____] Decisions Regarding Lifesaving and Life Prolonging Medical Treatment.
[____] Decisions Relating to Medical Treatment, Surgical Treatment, Nursing Care, Medication,
Hospitalization, Institutionalization in a nursing home or other facility and home health care.
[____] Transfer of Property or Income as a Gift to the Principal’s Spouse for the purpose of
qualifying the principal for governmental medical assistance.
[____] All OF THE ABOVE POWERS, INCLUDING FINANCIAL AND HEALTH CARE DECISIONS.
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This power of attorney shall take effect on the following date:
____/____/______
and will continue indefinitely or until revoked by me or by my death.
I do hereby grant my attorney in fact complete authority to act in any reasonable manner that
is necessary to execute the above mentioned powers that are granted.
I agree that any third party who is given a copy of this power of attorney may act relying on it. I
also agree that revocation of this power of attorney is effective as to a third party only upon
receipt of actual notice by the third party. I agree to indemnify the third party for any loss that
may be suffered while carrying out this power of attorney.
Signature & Acknowledgment
This contract shall be governed by the laws of the State of Indiana in __________ County and any
applicable Federal Law.
__________________________________________________________
Date____________
Signature
By accepting this appointment and acting under it, I the attorney-in-fact (“Agent”) do hereby assume the
legal responsibilities of an agent.
_____________________________________________________________________Date____________
Signature of Attorney-in-Fact
WITNESS #1) _________________________________
WITNESS #2) _________________________________
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