Power of Attorney Form for Adults With Disabilities
Use this form to provide the principal, attorney-in-fact, scope of authority, effective period, and signature details for a power of attorney arrangement.
Principal Information
Full Legal Name
*
First Name
Middle Name
Last Name
Preferred Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Attorney-in-Fact Information
Attorney-in-Fact Full Legal Name
*
First Name
Middle Name
Last Name
Relationship to Principal
*
Please Select
Spouse
Adult Child
Parent
Sibling
Other Family Member
Friend
Caregiver
Attorney
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Authority and Scope
Authorized Authority Categories
*
Financial matters
Property matters
Legal correspondence
Government benefits communications
Housing matters
Educational decisions
Other non-sensitive administrative matters
Limitations or Special Instructions
Effective Period and Communication
When should this authority become effective?
*
Immediately upon signing
On a specified date
Upon a future event
Effective date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Communication preferences or special delivery instructions
Confirmation and Signature
I confirm that I intend to grant the authority listed in this power of attorney.
*
I confirm
Principal Signature
*
Date Signed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Form
Submit Form
Should be Empty: