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Pharmacy power of attorney for... E-mail: pharmacy pharmacy.ok.gov ... This publication is issued by the Oklahoma State Board of Pharmacy as authorized by Title ..... Attorney General, Oklahoma Office of the ..... http://www.micromedex.com/products/pharmacists/

F00036 form If your agent is your spouse or domestic partner and your marriage is annulled or you are divorced or legally separated or the domestic partnership is terminated after signing this document the document is invalid. If you have questions about the Power of Attorney or the authority you are granting to your agent you should seek legal advice before signing this form. DEPARTMENT OF HEALTH SERVICES Division of Public Health F-00036 Rev. 09/10 STATE OF WISCONSIN Effective Date September 1 2010 s. State of Wisconsin Department of Health Services This Power of Attorney for Finances form allows you to plan for future financial decision-making even if you are unable to make your own decisions. More information is available to assist you in filling out this form1. This form is not the answer for everyone. Only select someone you trust to be your agent. You may wish to consult with an attorney to explore other financial planning tools such as a Power of Attorney for Finances drafted by an attorney or special accounts or trusts. This is an important legal document. Do not sign it until you and your chosen agent understand the powers being granted* By signing this document you are not giving up any powers or rights to control your finances or property. Instead you are giving your agent in addition to yourself the authority to handle your finances and property. While it is not required that you sign this document in the presence of a notary acknowledged signatures create a lawful presumption of genuineness and will be more easily accepted by businesses and financial institutions. This document is effective immediately when executed unless you state a future date or occurrence that will activate the powers expressed in this form* you specifically state that it terminates if you become incapacitated* If you name your spouse or domestic partner as your agent and the marriage or domestic partnership is terminated annulment or divorce this document becomes invalid unless the special instructions in this document state that such an action will not terminate the authority given to the agent. If you used a former state Power of Attorney for Finances form that form is still valid* Executing a new Power of Attorney for Finances does not automatically revoke a prior document. If you wish to change this Power of Attorney for Finances in the future you must complete a new document and revoke this one. You may revoke this document at any time a suggested method is a written and dated statement expressing your intent to revoke this document. If you revoke this document you should notify your agent and any other persons or entities that have a copy. In general an agent who is not the principal s spouse or domestic partner may not use the principal s property for the benefit of the agent or a person to whom the agent owes an obligation of support. Gifting to others is also generally not allowed2. Your agent is entitled to reasonable compensation unless you state otherwise in the special instructions.

South carolina power attorney... SOUTH CAROLINA HEALTH CARE POWER OF ATTORNEY INFORMATION ABOUT THIS DOCUMENT THIS IS AN IMPORTANT LEGAL DOCUMENT. I am not appointed as Health Care Agent or Successor Health Care Agent by this document. Witness No. 1 Signature Date Print Name Telephone This portion of the document is optional and is not required to create a valid health care power of attorney. STATE OF SOUTH CAROLINA COUNTY OF The foregoing instrument was acknowledged before me by Principal on Notary Public for South Carolina My Commission Expires. ADMINISTRATIVE PROVISIONS A. I revoke any prior Health Care Power of Attorney and any provisions relating to health care of any other prior power of attorney. A BENEFICIARY OF A LIFE INSURANCE POLICY ON YOUR LIFE. E. THE PERSONS NAMED IN THE HEALTH CARE POWER OF ATTORNEY AS YOUR AGENT OR SUCCESSOR AGENT. Second Alternate Agent Unavailability of Agent s If at any relevant time the agent or successor agents named here are unable or unwilling to make decisions concerning my health care and those decisions are to be made by a guardian by the Probate Court or by a surrogate pursuant to the Adult Health Care Consent Act it is my intention that the guardian Probate Court or surrogate make those decisions in accordance with my directions as stated in this document. EFFECTIVE DATE AND DURABILITY By this document I intend to create a durable power of attorney effective upon and only during any period of mental incompetence except as provided in Paragraph 3 below. I am not entitled to any portion of the principal s estate upon his decease whether under any will or as an heir by intestate succession nor am I the beneficiary of an insurance policy on the principal s life nor do I have a claim against the principal s estate as of this time. I am not the principal s attending physician nor an employee of the attending physician. No more than one witness is an employee of a health facility in which the principal is a patient. I am not appointed as Health Care Agent or Successor Health Care Agent by this document. Witness No. 1 Signature Date Print Name Telephone This portion of the document is optional and is not required to create a valid health care power of attorney. I sign my name to this Health Care Power of Attorney on this day of 20. My current home address is Principal s Signature Print Name of Principal I declare on the basis of information and belief that the person who signed or acknowledged this document the principal is personally known to me that he/she signed or acknowledged this Health Care Power of Attorney in my presence and that he/she appears to be of sound mind and under no duress fraud or undue influence. I am not related to the principal by blood marriage or adoption either as a spouse a lineal ancestor descendant of the parents of the principal or spouse of any of them. I am not directly financially responsible for the principal s medical care. I am not entitled to any portion of the principal s estate upon his decease whether under any will or as an heir by intestate succession nor am I the beneficiary of an insurance policy on the principal s life nor do I have a claim against the principal s estate as of this time. B. This power of attorney is intended to be valid in any jurisdiction in which it is presented. BY SIGNING HERE I INDICATE THAT I UNDERSTAND THE CONTENTS OF THIS DOCUMENT AND THE EFFECT OF THIS GRANT OF POWERS TO MY AGENT. I sign my name to this Health Care Power of Attorney on this day of 20. My current home address is Principal s Signature Print Name of Principal I declare on the basis of information and belief that the person who signed or acknowledged this document the principal is personally known to me that he/she signed or acknowledged this Health Care Power of Attorney in my presence and that he/she appears to be of sound mind and under no duress fraud or undue influence. I am not related to the principal by blood marriage or adoption either as a spouse a lineal ancestor descendant of the parents of the principal or spouse of any of them. I am not directly financially responsible for the principal s medical care.

Tn department of revenue forms TENNESSEE DEPARTMENT OF REVENUE POWER OF ATTORNEY PART 1 Power of Attorney (Please type or print.) Account number(s) 1. Taxpayer Information (Taxpayer must sign and date this form on line 6.) Taxpayer

Dea 222 form order Power of Attorney for DEA Forms 222 and Electronic Orders (Name of registrant) (Address of registrant) (DEA registration number) I, (name of person granting power), the undersigned, who am authorized

Geico report claim form GOVERNMENT EMPLOYEES INSURANCE COMPANIES A Shareholder Owned Company Not Affiliated With The U.S. Government HOME OFFICE WASHINGTON, D.C. 20076 FOR REPORTING ACCIDENTS REPORT ALL ACCIDENTS OR LOSSES

Durable power of attorney form 2. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE By this document I intend to create a Durable Power of Attorney by appointing the person designated subsequent incapacity. Date 12/17/2010 YOUTH INDEPENDENT LIVING PROGRAM FPO 0801C - Durable Power Of Attorney For Healthcare Decisions 1. First Alternative Agent B. Second Alternative Agent 8. PRIOR DESIGNATIONS REVOKED I revoke any prior Durable Power of Attorney for Healthcare YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY. I sign my name to this Durable Power of Attorney for Healthcare on Date City State Signature 9. WAIVER OF CONFLICT OF INTEREST. This Durable Power of Attorney for Health Care must be construed and interpreted in accordance with the laws of the State of Nevada. 11. WHAT is a Durable Power of Attorney Durable means that the document will remain in effect or take effect if you become mentally incompetent. You can also sign a durable power of attorney document to prepare for the possibility that you may become mentally incompetent due to illness or an accident. In exercising the authority under this Durable Power of Attorney for healthcare the authority of my agent is subject to the following special provisions and limitations 5. The relative or friend you choose to be your Agent will be acting for you regarding your healthcare issues. You need to choose someone who won t abuse the powers you give them and will look out for your best interests. WHAT is the Difference Between a POA and a Living Will Living Will because it allows you to choose someone only allows you to communicate your wishes concerning life-sustaining procedures. IS the POA an Advanced Heath Care Directive Both Living Wills and Healthcare Powers of Attorney are considered Advance Healthcare Directives because you re giving instructions on what you d want to happen in the event that you become unable Nevada also has a specific Advance Healthcare Directive document that combines elements of a a more in-depth look at Advance Healthcare Directives Healthcare Powers of Attorney and Living Wills link to http //nvsos. gov/index. aspx page 214 DO I have to Choose a Lawyer to be My Agent You don t have to choose a lawyer to be your Agent but it is important to select someone you trust. WHAT if the Person I Choose as Agent is Unable to Serve There is always the possibility that the person or organization you choose as your Agent either won t be able to serve or will refuse to serve. That s why you have the option of choosing a Successor Agent or second Agent who can take over as Agent if necessary. Here is an example of why choosing a Suc- cessor Agent is a good idea A young adult chooses a former teacher as their Agent. The teacher moves across the country to care for an aging parent and is no longer available to make decisions on behalf of the youth. If the youth had chosen a Successor Agent that person is then able to make decisions if necessary. WHERE Do I Get the Document Your caseworker will provide you with the POA document during your transition plan meeting.

Us bank power of attorney form LIMITED POWER OF ATTORNEY Know all men by these presents, that, I, of , do hereby make, constitute and appoint my my true and lawful attorney-in-fact for me in my name, place and stead to do, execute

Tn power attorney vehicle form Print Tennessee Department of Revenue Taxpayer and Vehicle Services Division Reset POWER OF ATTORNEY FOR VEHICLE TRANSACTIONS (Tenn. Code Ann. 34-6-101 and 102) Dealers must use a secure power of

Power of attorney new york sta... New York State Bar Association Statutory Short Form Durable Power of Attorney 7/28/09 Power of Attorney New York Statutory Short Form a CAUTION TO THE PRINCIPAL YOUR POWER OF ATTORNEY IS AN IMPORTANT DOCUMENT. AS THE PRINCIPAL YOU GIVE THE PERSON WHOM YOU CHOOSE YOUR AGENT AUTHORITY TO SPEND YOUR MONEY AND SELL OR DISPOSE OF YOUR PROPERTY DURING YOUR LIFETIME WITHOUT TELLING YOU. YOU DO NOT LOSE YOUR AUTHORITY TO ACT EVEN THOUGH YOU HAVE GIVEN YOUR AGENT SIMILAR AUTHORITY. WHEN YOUR AGENT EXERCISES THIS AUTHORITY HE OR SHE MUST ACT ACCORDING TO ANY INSTRUCTIONS YOU HAVE PROVIDED OR WHERE THERE ARE NO SPECIFIC INSTRUCTIONS IN YOUR BEST INTEREST. IMPORTANT INFORMATION FOR THE AGENT AT THE END OF THIS DOCUMENT DESCRIBES YOUR AGENT S RESPONSIBILITIES* YOUR AGENT CAN ACT ON YOUR BEHALF ONLY AFTER SIGNING THE BEFORE A NOTARY PUBLIC. POWER OF ATTORNEY YOU CAN REQUEST INFORMATION FROM YOUR AGENT AT ANY TIME* IF YOU ARE REVOKING A PRIOR POWER OF ATTORNEY BY EXECUTING THIS POWER OF ATTORNEY YOU SHOULD PROVIDE WRITTEN NOTICE OF THE REVOCATION TO YOUR PRIOR AGENT S AND TO THE FINANCIAL INSTITUTIONS WHERE YOUR ACCOUNTS ARE LOCATED. YOU CAN REVOKE OR TERMINATE YOUR POWER OF ATTORNEY AT ANY TIME FOR ANY REASON AS LONG AS YOU ARE OF SOUND MIND. IF YOU ARE NO LONGER OF SOUND MIND A COURT CAN REMOVE AN AGENT FOR ACTING IMPROPERLY. YOUR AGENT CANNOT MAKE HEALTH CARE PROXY TO DO THIS* THE HEALTH CARE DECISIONS FOR YOU. MAY EXECUTE A POWERS OF ATTORNEY IS CONTAINED IN THE NEW YORK GENERAL OBLIGATIONS LAW ARTICLE 5 TITLE 15. THIS LAW IS AVAILABLE AT A LAW LIBRARY OR ONLINE THROUGH THE NEW YORK STATE SENATE OR ASSEMBLY WEBSITES WWW*SENATE*STATE*NY. US OR WWW*ASSEMBLY. STATE*NY. US* LAW GOVERNING If there is anything about this document that you do not understand you should ask a lawyer of your own choosing to explain it to you. b DESIGNATION OF AGENT S I hereby appoint name and address of principal IF YOU DESIGNATE MORE THAN ONE AGENT ABOVE THEY MUST ACT TOGETHER UNLESS YOU INITIAL THE STATEMENT BELOW* My agents may act SEPARATELY. If every agent designated above is unable or unwilling to serve I appoint as my successor agent s Successor agents designated above must act together unless you initial the statement below. My successor agents may act SEPARATELY. d This POWER OF ATTORNEY shall not be affected by my subsequent incapacity unless I have stated otherwise below under Modifications. me unless I have stated otherwise below under Modifications. IF YOU ARE NOT REVOKING YOUR PRIOR SAME AUTHORITY IN TWO OR MORE MODIFICATIONS WHETHER THE AGENTS GIVEN THESE POWERS ARE TO ACT TOGETHER OR SEPARATELY. f GRANT OF AUTHORITY TO GRANT YOUR AGENT SOME OR ALL OF THE AUTHORITY BELOW EITHER 1 INITIAL THE BRACKET AT EACH AUTHORITY YOU GRANT OR 2 WRITE OR TYPE THE LETTERS FOR EACH AUTHORITY YOU GRANT ON THE BLANK LINE AT P AND INITIAL THE BRACKET AT P. IF YOU INITIAL P YOU DO NOT NEED TO INITIAL THE OTHER LINES* I grant authority to my agent s with respect to the following subjects as defined in sections 51502A through 5-1502N of the New York General Obligations Law A B C D E F G H I J K L M N O real estate transactions chattel and goods transactions bond share and commodity transactions banking transactions business operating transactions insurance transactions estate transactions claims and litigation personal and family maintenance benefits from governmental programs or civil or military service health care billing and payment matters records reports and statements retirement benefit transactions tax matters all other matters full and unqualified authority to my agent s to delegate any or all of the foregoing powers to any person or persons whom my agent s select EACH of the matters identified by the following letters You need not initial the other lines if you initial line P.

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