Fillable Printable Durable Power of Attorney Example - Washington

Durable Power of Attorney Example - Washington

Filed for record at the request of:

______________________________

DURABLE POWER OF ATTORNEY

I, ______________________________, resident of the State of Washington,

revoke any powers of attorney I may have given in the past and give

______________________________________ (referred to below as "the agent")

a durable power of attorney. I intend that it not be limited by any disability I may

have in the future.

1. POWERS

A. The agent shall act on my behalf and for my benefit, and shall have all

powers over my estate that I have or acquire. These shall include, but not be

limited to, the following: the power to make deposits to, and payments from, any

account in my name in any financial institution; the power to open and remove

items from any safe deposit box in my name; the power to sell, exchange or transfer

title to stocks, bonds or other securities; the power to sell, convey or encumber

any real or personal property.

B. The agent shall have the power to consent to, or to withhold consent

from, medical treatment, shall have all powers necessary or desirable to provide

for my support, maintenance, health and comfort; the agent shall be entitled to

obtain and use any of my medical records or other individually identifiable health

information to the same extent as I would myself. This is intended as a full

release of all information governed by the Health Insurance Portability and

Accountability Act of 1996 (HIPAA).

C. I authorize the agent to revoke any community property agreement and

to transfer any property to my spouse or registered domestic partner as a gift.

_____ (Initial here if revocation of a community property agreement and gifts to

a spouse or registered domestic partner are authorized. If they are not authorized,

cross out all of paragraph C.)

D. I authorize the agent to make gifts of my property to the following

person or persons: _____________________________________________.

Gifts under this paragraph may be:

_____ in any amount

_____ not more than $_____________ per year

(If gifts are authorized under paragraph D, either initial next to “in any amount”

or initial next to “no more than” and fill in a dollar amount. If gifts are not

authorized, cross out all of paragraph D.)

No gift may be made under this power of attorney, except to a spouse or

registered domestic partner if authorized under paragraph 1(C), unless authorized

by this paragraph.

2. EFFECTIVE DATE, REVOCATION AND DISPOSITION OF REMAINS

A. This power of attorney shall become effective (initial the choice that

applies):

1. ________ immediately

2. ________only when my agent, who may consult with any medical and/or legal

professionals as he/she deems necessary or appropriate, certifies in writing that I lack the

mental capacity to make important decisions independently. (This certification may be

made using the box at the end of this document, or may be made in a separate

writing.)

For purposes of obtaining information from a physician to determine if I am

incapacitated, my agent shall be entitled to obtain and use any of my medical records or

other individually identifiable health information to the same extent as I would myself.

This is intended as a full release of all information governed by the Health Insurance

Portability and Accountability Act of 1996 (HIPAA).

3. ________ only when my incompetence or disability has been established by a written,

dated statement signed by a qualified physician who has regularly attended me for the last

two most recent years prior to disability or incompetence, or, in the absence of such a

physician, by the unanimous agreement of two qualified physicians who have examined

me and reviewed my medical history. (This certification may be made using the box at

the end of this document, or may be made in a separate writing.).

For purposes of obtaining a certification of incompetency or disability from a

physician, my agent shall be entitled to obtain and use any of my medical records or other

individually identifiable health information to the same extent as I would myself. This is

intended as a full release of all information governed by the Health Insurance Portability

and Accountability Act of 1996 (HIPAA).

B. This power of attorney shall remain in effect until revoked or until my death.

C. After my death, my agent shall have the authority to act as my

representative for purposes of controlling the disposition of my remains, as

authorized under RCW 68.50.16, if I have not otherwise made lawful provision

for their disposition.

D. I may revoke this power of attorney by giving written notice to the agent

and, if the power of attorney has been recorded, by recording the written

instrument of revocation in the county office where deeds are recorded.

E. If I give notice of revocation after my agent has certified that I lack the

mental capacity to make important decisions, then my agent’s power or attorney

shall be suspended unless and until a court determines that the revocation was not

effective.

3. RIGHTS AND DUTIES OF THE AGENT

A. My estate shall hold the agent harmless from, and indemnify the agent

for, all liability for acts done for me in good faith based on this power of attorney.

B. The agent shall be required to account to any subsequently appointed

personal representative.

4. NOMINATION OF GUARDIAN

I nominate the agent for consideration by the court as my guardian or

limited guardian in the event that any guardianship proceeding for my person or

estate should be commenced.

5. SUBSTITUTE AGENT

I appoint _________________________________ to serve as substitute

agent in place of the agent named in paragraph 1 above, if the agent named in

paragraph 1 is unable or unwilling to serve. A statement signed by the substitute

agent, affirming that the agent named in paragraph 1 is unable or unwilling to

serve shall be sufficient to establish that the agent is unable or unwilling to serve.

(If no substitute agent is named, this paragraph should be crossed out.)

Dated:

On ______________, a person I know to be_____________________________

appeared before me in person, signed above, and acknowledged that the signing

was done freely and voluntarily for the purposes mentioned above.

Dated: ___________________________________

______________________________

Notary Public, State of Washington,

residing at:

Commission expires:

Certification of Incapacity

(Certification by Agent)

I certify that the principal lacks the mental capacity to make important decisions

independently.

dated: _________________________

_______________________________

signature

printed name: ______________________________

address: _______________________________________

________________________________________

telephone: _______________________________________

Certification of Incapacity

(Certification by Regular Attending Physician)

I certify that I am a medical doctor, that I have regularly attended the principal and in my

opinion the principal is now incompetent or disabled as defined in paragraph 1 of this

document due to a lack of mental capacity to make important decisions independently

and/or for the following reason:

dated: _________________________

_______________________________

signature

printed name: ______________________________

address: _______________________________________

________________________________________

telephone: _______________________________________

Certification of Incapacity

(Certification by Qualified Physicians in the Absence of a Regular Attending

Physician)

The undersigned each certify that he/she is a medical doctor, that he/she has examined

the principal and reviewed the principal’s medical history, and that in the opinion of the

undersigned, the principal is now incompetent or disabled as defined in paragraph 1 of

this document due to a lack of mental capacity to make important decisions

independently and/or for the following reason:

_____________________________________

dated: _________________________

_______________________________

signature

printed name: ______________________________

address: _______________________________________

________________________________________

telephone: _______________________________________

dated: _________________________

_______________________________

signature

printed name: ______________________________

address: _______________________________________

________________________________________

telephone: _______________________________________