Fillable Printable Durable Power of Attorney Form - Alabama
Fillable Printable Durable Power of Attorney Form - Alabama
Durable Power of Attorney Form - Alabama
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ALABAMA DURABLE POWER OF ATTORNEY FORM
IMPORTANT INFORMATION
This power of attorney authorizes another person (your agent) to make
decisions concerning your property for you (the principal). Your agent will be
able to make decisions and act with respect to your property (including your
money) whether or not you are able to act for yourself. The meaning of
authority over subjects listed on this form is explained in the Alabama
Uniform Power of Attorney Act, Chapter 1A, Title 26, Code of Alabama 1975.
This power of attorney does not authorize the agent to make health care
decisions for you. Such powers are governed by other applicable law.
You should select someone you trust to serve as your agent. Unless you
specify otherwise, generally the agent's authority will continue until you die
or revoke the power of attorney or the agent resigns or is unable to act for
you.
Your agent is entitled to reimbursement of reasonable expenses and
reasonable compensation unless you state otherwise in the Special
Instructions.
This form provides for designation of one agent. If you wish to name more
than one agent you may name a co-agent in the Special Instructions. Co-
agents are not required to act together unless you include that requirement
in the Special Instructions.
If your agent is unable or unwilling to act for you, your power of attorney
will end unless you have named a successor agent. You may also name a
second successor agent.
This power of attorney becomes effective immediately unless you state
otherwise in the Special Instructions.
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.
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STATE OF ALABAMA )
______________ COUNTY )
Durable Power of Attorney and Authority to Access Health
Information
Of
_____________________________
KNOW ALL MEN BY THESE PRESENTS that I, ____________________
of ________________________ in ____________________ County,
Alabama, do hereby make, constitute and appoint
_____________________________of ___________________, in
__________________ County, Alabama, phone number _____________ ,as
my Attorney-in-Fact, for me and in my name, place and stead, and on my
behalf, to do, perform and execute the acts I have authorized, and I grant to
him/her every power necessary to carry out the purposes for which this
power is granted, including the powers of revocation and substitution,
hereby ratifying and affirming that which (s)he or his/her substitute shall
lawfully do or cause to be done by virtue of the rights and powers herein
granted.
This power of attorney shall not be affected by disability,
incompetency, or incapacity of the principal.
GRANT OF GENERAL AUTHORITY
I grant my agent and any successor agent general authority to act for me
with respect to the following subjects as defined in the Alabama Uniform
Power of Attorney Act, Chapter 1A, Title 26, Code of Alabama 1975:
If you wish to grant general authority over all of the subjects enumerated in
this section you may SIGN here:
________________________________________________
(Signature of Principal)
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OR
If you wish to grant specific authority over less than all subjects enumerated
in this section you must INITIAL by each subject you want to include in the
agent's authority:
_____Real Property as defined in Section 26-1A-204
_____Tangible Personal Property as defined in Section 26-1A-205
_____Stocks and Bonds as defined in Section 26-1A-206
_____Commodities and Options as defined in Section 26-1A-207
_____Banks and Other Financial Institutions as defined in Section 26-1A-208
_____Operation of Entity or Business as defined in Section 26-1A-209
_____Insurance and Annuities as defined in Section 26-1A-210
_____Estates, Trusts, and Other Beneficial Interests as defined in Section
26-1A-211
_____Claims and Litigation as defined in Section 26-1A-212
_____Personal and Family Maintenance as defined in Section 26-1A-213
_____Benefits from Governmental Programs or Civil or Military Service as
defined in Section 26-1A-214
_____Retirement Plans as defined in Section 26-1A-215
_____Taxes as defined in Section 26-1A-216
_____Gifts as defined in Section 26-1A-217
GRANT OF SPECIFIC AUTHORITY (OPTIONAL)
My agent MAY NOT do any of the following specific acts for me UNLESS I
have INITIALED the specific authority listed below:
(CAUTION: Granting any of the following will give your agent the authority
to take actions that could significantly reduce your property or change how
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your property is distributed at your death. INITIAL the specific authority you
WANT to give your agent.)
_____Create, amend, revoke, or terminate an inter vivos trust, by trust or
applicable law
_____Make a gift to which exceeds the monetary limitations of Section 26-
1A-217 of the Alabama Uniform Power of Attorney Act, but subject to any
special instructions in this power of attorney
_____Create or change rights of survivorship
_____Create or change a beneficiary designation
_____Authorize another person to exercise the authority granted under this
power of attorney
_____Waive the principal's right to be a beneficiary of a joint and survivor
annuity, including a survivor benefit under a retirement plan
_____Exercise fiduciary powers that the principal has authority to delegate
AUTHORITY TO ACCESS HEALTH INFORMATION
My agent MAY NOT do any of the following specific acts for me UNLESS I
have INITIALED the specific authority listed below:
______Arrange for my care at home or by admitting me to an appropriate
facility, and, effective immediately, to serve as my personal
representative as that term is used in 45 CFR 164.502 (commonly
known as “HIPAA privacy regulations”), and to have the same access
to my personal health information as I have myself, including, but not
limited to, viewing and obtaining copies of any and all of my personally
identifiable medical records of any kind whatever, and consulting with
medical providers; and I authorize covered medical Entities to provide
such access and to cooperate with my agent under this document [as
well as any health care agent or proxy I may appoint]; [further, my
agent appointed herein may make medical decisions for me, consistent
with applicable law and with any health care directive I may have in
effect at the time decisions may be needed.] [I do not intend, by this
appointment, to prohibit other family members from access to my
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otherwise private health care information, and I authorize covered
entities to provide to ____________________, the same access to
them and cooperation with them to which I am entitled myself.]
LIMITATIONS ON AGENT'S AUTHORITY
An agent that is not my ancestor, spouse, or descendant MAY NOT use my
property to benefit the agent or a per-son to whom the agent owes an
obligation of support unless I have included that authority in the Special
Instructions.
Limitation of Power. Except for any special instructions given herein to the
agent to make gifts, the following shall apply:
(a) Any power or authority granted to my Agent herein shall be limited so as
to prevent this Power of Attorney from causing any Agent to be taxed on my
income or from causing my assets to be subject to a "general power of
appointment" by my Agent as defined in 26 U.S.C. Section 2041 and 26
U.S.C. Section 2514 of the Internal Revenue Code of 1986, as amended.
(b) My Agent shall have no power or authority whatsoever with respect to
any policy of insurance owned by me on the life of my Agent, or any trust
created by my Agent as to which I am a trustee.
SPECIAL INSTRUCTIONS (OPTIONAL)
You may give special instructions on the following lines. For your protection,
if there are no special instructions write NONE in this section.
___________________________________________________________
NOMINATION OF [CONSERVATOR OR GUARDIAN] (OPTIONAL)
If it becomes necessary for a court to appoint a [conservator or guardian] of
my estate or [guardian] of my person, I nominate the following person(s) for
appointment:
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Name of Nominee for [conservator or guardian] of my estate:
__________________________
Nominee's Address: _________________________________________
_________________________________________
Nominee's Telephone Number: ____________________
Name of Nominee for [guardian] of my person:
_______________________________
Nominee's Address: __________________________________________
__________________________________________
Nominee's Telephone Number: ________________________
EFFECTIVE DATE
This power of attorney is effective immediately unless I have stated
otherwise in the Special Instructions.
RELIANCE ON THIS POWER OF ATTORNEY
Any person, including my agent, may rely upon the validity of this power of
attorney or a copy of it unless that person knows it has terminated or is
invalid.
SIGNATURE AND ACKNOWLEDGMENT
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____________________________________________
(Signature of Principal)
Your Signature Date:___________________________
Your Name Printed:___________________________
Your Address:_____________________
Your Telephone Number:_______________________
STATE OF ALABAMA
_______________ COUNTY
I, ________________, a Notary Public, in and for the County in this
State, hereby certify that ______________, whose name is signed to the
foregoing document, and who is known to me, acknowledged before me on
this day that, being informed of the contents of the document, he or she
executed the same voluntarily on the day the same bears date.
Given under my hand this the ___ day of ______, 20___.
_______________________________________(Seal, if any)
Signature of Notary
My commission expires: _______________________
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IMPORTANT INFORMATION FOR AGENT
Agent's Duties
When you accept the authority granted under this power of attorney, a
special legal relationship is created between you and the principal. This
relationship imposes upon you legal duties that continue until you resign or
the power of attorney is terminated or revoked. You must:
(1) do what you know the principal reasonably expects you to do with the
principal's property or, if you do not know the principal's expectations, act in
the principal's best interest;
(2) act in good faith;
(3) do nothing beyond the authority granted in this power of attorney; and
(4) disclose your identity as an agent whenever you act for the principal by
writing or printing the name of the principal and signing your own name as
"agent" in the following manner:
(Principal's Name) by (Your Signature) as Agent
Unless the Special Instructions in this power of attorney state otherwise, you
must also:
(1) act loyally for the principal's benefit;
(2) avoid conflicts that would impair your ability to act in the principal's best
interest;
(3) act with care, competence, and diligence;
(4) keep a record of all receipts, disbursements, and transactions made on
behalf of the principal;
(5) cooperate with any person that has authority to make health care
decisions for the principal to do what you know the principal reasonably
expects or, if you do not know the principal's expectations, to act in the
principal's best interest; and
(6) attempt to preserve the principal's estate plan if you know the plan and
preserving the plan is consistent with the principal's best interest.
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Termination of Agent's Authority
You must stop acting on behalf of the principal if you learn of any event that
terminates this power of attorney or your authority under this power of
attorney. Events that terminate a power of attorney or your authority to act
under a power of attorney include:
(1) death of the principal;
(2) the principal's revocation of the power of attorney or your authority;
(3) the occurrence of a termination event stated in the power of attorney;
(4) the purpose of the power of attorney is fully accomplished; or
(5) if you are married to the principal, a legal action is filed with a court to
end your marriage, or for your legal separation, unless the Special
Instructions in this power of attorney state that such an action will not
terminate your authority.
Liability of Agent
The meaning of the authority granted to you is defined in the Alabama
Uniform Power of Attorney Act, Chapter 1A, Title 26, Code of Alabama 1975.
If you violate the Alabama Uniform Power of Attorney Act, Chapter 1A, Title
26, Code of Alabama 1975, or act outside the authority granted, you may be
liable for any damages caused by your violation.
If there is anything about this document or your duties that you do not
understand, you should seek legal advice.
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AGENT'S CERTIFICATION AS TO THE VALIDITY OF POWER OF
ATTORNEY AND AGENT'S AUTHORITY
STATE OF ALABAMA
COUNTY OF __________________
I, _________________________________________ (Name of Agent),
certify under penalty of perjury that ________________________________
granted me authority as an agent or successor agent in a power of attorney
dated ________________________.
I further certify that to my knowledge:
(1) the Principal is alive and has not revoked the Power of Attorney or my
authority to act under the Power of Attorney and the Power of Attorney and
my authority to act under the Power of Attorney have not terminated;
(2) if the Power of Attorney was drafted to become effective upon the
happening of an event or contingency, the event or contingency has
occurred;
(3) if I was named as a successor agent, the prior agent is no longer able or
willing to serve; and
(4) __________________________________________
SIGNATURE AND ACKNOWLEDGMENT
_________________________________________________
Agent's Signature Date:
_________________________________________________
Agent's Name Printed:
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_________________________________________________
Agent's Address:
_________________________________________________
Agent's Telephone Number:
_________________________________________________
This document was acknowledged before me on
________________________________________________,
(Date)
by______________________________________________.
(Name of Agent)
___________________________________________ (Seal, if any)
Signature of Notary
My commission expires: ________________________
