POWER OF ATTORNEY INFORMATION SHEET
Personal Information
Name: _________________________________________________________________
Address: _______________________________________________________________
Phone: Alternate Phone: ____________________________________________________
Social Security Number: ____________________________________________________
Date of Birth: ____________________________________________________________
Who do you wish to make decisions on your behalf concerning matters such as:
Real property transactions;
Tangible personal property transactions;
Stock bond transactions;
Commodity and option 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 governmental programs or civil or military service
Retirement plan transactions;
Tax matters.
1st Choice for Durable Power of Attorney
Name: __________________________________________________________________
Address: _________________________________________________________________
Telephone: _______________________________________________________________
Relationship: ______________________________________________________________
2nd Choice for Durable Power of Attorney
Name: ___________________________________________________________________
Address: _________________________________________________________________
Telephone: ________________________________________________________________
Relationship: _______________________________________________________________
Who do you wish to make healthcare decisions on your behalf should you become too ill to make your own healthcare or medical decisions.
1st Choice for Healthcare Power of Attorney
Name: ___________________________________________________________________
Address: _________________________________________________________________
Telephone: ________________________________________________________________
Relationship: _______________________________________________________________
2nd Choice for Healthcare Power of Attorney
Name: ___________________________________________________________________
Address: _________________________________________________________________
Telephone: ________________________________________________________________
Relationship: _______________________________________________________________
After completion, return to:
The Law Offices of
CARROLL & HINOJOSA, PLLC
2117 Pat Booker, Suite B
Universal CIty, Texas 78148
Telephone (210) 650-9074
Facsimile (210) 650-3291