Sample card

x
Attorney(s): Number:
Gender:
Mode:
Alternate attorney(s): Number:
Gender:
Mode:
Second alternate attorney(s): Number:
Gender:
Mode:
Third alternate attorney(s): Number:
Gender:
Mode:

I,
name to be my attorney for personal care.
If he cannot or will not be my attorney I name to be my attorney for personal care.
If he cannot or will not be my attorney I name to be my attorney for personal care.
If he cannot or will not be my attorney I name to be my attorney for personal care.
I confer on my attorney authority to make a decision about my personal care that I am mentally incapable of making myself.
This power of attorney for personal care was signed on , by in our presence, and each of us signed it as witness.

Telephone number(s) for < ............... >:

Telephone number(s) for < ............... >:

Telephone number(s) for < ............... >:

Telephone number(s) for < ............... >:

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