Durable Power of Attorney Documents - WashingtonLawHelp.org

August 2018

Durable Power of Attorney Documents

What is a power of attorney document?

A power of attorney document lets you choose

a trusted friend or relative to help you with your

finances and/or health care decisions. After you

sign it, the person you choose will take the

power of attorney document to your medical

providers, bank, school, and other places to

make decisions and sign contracts just as if he

or she were you.

The trusted friend or relative you choose to help

you with your finances and/or health care

decisions is called your “agent.”

Do I need to sign my documents in front

of a notary?

You must sign your Durable Power of Attorney

document in front of either a notary or two

witnesses. The two witnesses cannot be

a health care provider in your home or long-

term care facility nor can they be related to you

by blood, marriage or state registered domestic

partnership.

It is a good idea to sign your Durable Power of

Attorney for Finances in front of a

notary because some banks and government

agencies require these documents to be

notarized.

After you sign your documents, make two

copies. Give the original document to your

agent, give one copy to your alternate agent,

and keep the second copy for yourself.

Can I change my Power of Attorney

documents and choose a new agent?

You can revoke (cancel) your power of attorney

document at any time with a written notice to

your agent. A sample “Notice of Revocation” is

included in this packet. You can also give a copy

of this written notice to your medical providers,

bank, school, and other places that might accept

the old power of attorney document.

What if I need legal help?

If you live outside King County, call the CLEAR

hotline Monday-Friday from 9:15 am to 12:15

pm at 1-888-201-1014. You can also apply

online at http://nwjustice.org/get-legal-help.

If you live in King County, call 211 for

information and referral to a legal services

provider Monday-Friday from 8:00 am to 6:00

pm. You can find more information online at

www.resourcehouse.com/win211/.

Deaf, hard of hearing or speech impaired callers

can call CLEAR or 211 (or toll-free 1-877-211-

9274) using the relay service of their choice.

This publication provides general information concerning your rights and responsibilities. It is not intended as a substitute for specific legal

advice. This information is current as of August 2018.

Permission for copying and distribution granted to the Alliance for Equal Justice and to individuals for non-commercial purposes.

Durable Power of Attorney for Finances – Page 1 of 3

©Seattle University School of Law Clinical Program & Northwest Justice Project

Durable Power of Attorney for Finances

for

______________________________________________________________

[My Name]

1. Agent. I choose ______________________________as my Agent with full authority to

manage my finances.

2. Alternate. If ______________________________is unable or unwilling to act, I choose

_____________________________ as my Agent with full authority to manage my finances.

3. My Rights. I keep the right to make financial decisions for myself as long as I am capable.

4. Durable. My Agent can use this power of attorney document to manage my finances even if

I become sick or injured and cannot make decisions for myself. This power of attorney

document shall not be affected by my disability.

5. Start Date. This power of attorney document is effective: (check one)

 Immediately.

 Only if my medical provider signs a letter saying I cannot make decisions for myself.

6. End Date. This power of attorney document will end if I revoke it or when I die. If my spouse

or domestic partner is my Agent, this power of attorney document will end if either of us

files for divorce in court.

7. Revocation. I revoke any power of attorney for finances documents I have signed in the

past. I understand that I may revoke this power of attorney document at any time by giving

written notice of revocation to my Agent.

8. Powers. My Agent shall have full power and authority to do anything as fully and effectively

Durable Power of Attorney for Finances – Page 2 of 3

©Seattle University School of Law Clinical Program & Northwest Justice Project

as I could do myself, including, but not limited to, the power to make deposits to, and

payments from, any account in my name in any financial institution, to open and remove

items from any safe deposit box in my name, to sell, exchange or transfer title to stocks,

bonds or other securities, and to sell, convey or encumber any real or personal property. My

agent shall also have the following special powers: (check all that apply)

 create, amend, revoke, or terminate a living trust

 make gifts of my money or property

 create or change my rights of survivorship

 create or change my beneficiary designation(s)

 delegate some authority granted in this document to someone else

 waive my right to be the beneficiary of an annuity or retirement plan

 create, amend, revoke, or terminate my community property agreement

 tell a trustee to make distributions from a trust just as I could

9. No Power to Agree to Binding Pre-Dispute Arbitration. I recognize that some long-term-care

providers will ask me or my Agent to sign a binding pre-dispute arbitration agreement.

These agreements limit my right to sue the provider before any injury or dispute occurs. I

think these agreements are unfair and unacceptable. Therefore, my agent does not have

the power to agree to pre-dispute binding arbitration or any other process involving my

person or property that limits my right to a jury, to sue for money, or to join a class action.

10. Accounting. My Agent shall keep accurate records of my finances and show these records

to me at my request.

11. Nomination of Guardian. I nominate my Agent as the guardian of my estate for

consideration by the court if guardianship proceedings become necessary.

Durable Power of Attorney for Finances – Page 3 of 3

©Seattle University School of Law Clinical Program & Northwest Justice Project

12. HIPAA Release. I authorize my healthcare providers to release all information governed by

the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to my Agent.

_________________________________________ _____________________

My Signature Date

Notarization (optional, but recommended)

State of Washington

County of _______________________

I certify that I know or have satisfactory evidence that_________________________________, is the person

who appeared before me, signed above, and acknowledged that the signing was done freely and voluntarily

for the purposes mentioned in this instrument.

SUBSCRIBED and SWORN to before me on _____________________.

______

SIGNATURE OF NOTARY

PRINT NAME OF NOTARY

NOTARY PUBLIC for the State of Washington.

My commission expires .

Witness 1 Witness 2

__________________________________ ____________________________________

Signature Signature

__________________________________ ____________________________________

Name Name

__________________________________ ____________________________________

Address Address

Durable Power of Attorney for Health Care – Page 1 of 2

©Seattle University School of Law Clinical Program & Northwest Justice Project

Durable Power of Attorney for Health Care

for

________________________________________________________

[My Name]

1. Agent. I choose ______________________________as my Agent with full authority to manage my

health care.

2. Alternate. If ______________________________is unable or unwilling to act, I choose

___________________________as my Agent with full authority to manage my health care.

3. My Rights. I keep the right to make health care decisions for myself as long as I am capable.

4. Durable. My Agent can still use this power of attorney document to manage my affairs even if I

become sick or injured and cannot make decisions for myself. This power of attorney shall not be

affected by my disability.

5. Start Date. This power of attorney document is effective on the day I sign it in front of a notary

public.

6. End Date. This power of attorney document will end if I revoke it or when I die. If my spouse or

domestic partner is my Agent, this power of attorney document will end if either of us files for

divorce in court.

7. Revocation. I revoke any other power of attorney for health care documents I have signed in the

past. I understand that I may revoke this power of attorney document at any time by giving written

notice of revocation to my Agent.

8. Powers. My Agent shall have full power and authority to do anything as fully and effectively as I

could do myself, including the power to make health care decisions and give informed consent to my

health care, refuse and withdraw consent to my health care, employ and discharge my health care

providers, apply for and consent to my admission to a medical, nursing, residential or other similar

facility that is not a mental health treatment facility, serve as my personal representative for all

purposes under the Health Insurance Portability and Accountability Act (HIPAA) of 1996, as

amended, and to visit me at any hospital or other medical facility where I reside or receive

treatment

9. Mental Health Treatment. My Agent is not authorized to arrange for my commitment to or

placement in a mental health treatment facility. My Agent is not authorized to consent to

electroconvulsive therapy, psychosurgery, or other psychiatric or mental health procedures that

restrict physical freedom of movement.

10. No Power to Agree to Binding Pre-Dispute Arbitration. I recognize that some long-term-care providers

will ask me or my Agent to sign a binding pre-dispute arbitration agreement. These agreements limit

my right to sue the provider before any injury or dispute occurs. I think these agreements are unfair

and unacceptable. Therefore, my agent does not have the power to agree to pre-dispute binding

Durable Power of Attorney for Health Care – Page 2 of 2

©Seattle University School of Law Clinical Program & Northwest Justice Project

arbitration or any other process involving my person or property that limits my right to a jury, to sue

for money, or to join a class action.

11. Accounting. My Agent shall keep accurate records of my financial affairs and show these records to

me at my request.

12. Nomination of Guardian. I nominate my Agent as the guardian of my person for consideration by the

court if guardianship proceedings become necessary.

13. HIPAA Release. I authorize my healthcare providers to release all information governed by the

Health Insurance Portability and Accountability Act of 1996 (HIPAA) to my Agent.

_________________________________________ _____________________

My Signature Date

Witness 1 Witness 2

__________________________________ ____________________________________

Signature Signature

__________________________________ ____________________________________

Name Name

__________________________________ ____________________________________

Address Address

Notarization (Optional)

State of Washington

County of _______________________

I certify that I know or have satisfactory evidence that_________________________________, is the person

who appeared before me, signed above, and acknowledged that the signing was done freely and voluntarily

for the purposes mentioned in this instrument.

SUBSCRIBED and SWORN to before me on _____________________.

SIGNATURE OF NOTARY

PRINT NAME OF NOTARY

NOTARY PUBLIC for the State of Washington.

My commission expires .

Power of Attorney Revocation

Revocation of Durable Power of Attorney

for

 Finances

 Health Care

I, ______________________________, hereby revoke the Durable Power of Attorney I gave to

________________________________.

_______________________________________ _________________

Signature Date

Notarization (optional)

State of Washington

County of _______________________

I certify that I know or have satisfactory evidence that_________________________________, is the person

who appeared before me, signed above, and acknowledged that the signing was done freely and voluntarily

for the purposes mentioned in this instrument.

SUBSCRIBED and SWORN to before me on _____________________.

SIGNATURE OF NOTARY

PRINT NAME OF NOTARY

NOTARY PUBLIC for the State of Washington.

My commission expires .

Durable Power of Attorney Documents - Glossary

Glossary

Here are some terms you may find helpful when reading a power of attorney document:

 Agent: the trusted person you choose to help you with your finances or health care.

 Beneficiary: the person who gets money or property. For example, if you have life insurance and

you die, the person who gets the insurance money is called a beneficiary. The person who gets

money or property from a trust is also called a beneficiary.

 Beneficiary Designation: the part of a contract that says who should be the beneficiary. For

example, the beneficiary designation in a life insurance policy is the part that says who will get

the money after you die.

 Binding Arbitration: a process for resolving legal disputes with a company outside of a court.

Usually, arbitration limits your right to a jury trial, limits the amount of money you can be

awarded, and prevents you from bringing a class action lawsuit against the company. Also,

arbitrators are usually picked by the company.

 Community Property Agreement: a written agreement between a married couple or domestic

partners that says when one dies, all of their property will automatically go to the other.

 Durable: “Durable” means your document still has legal power and agent can keep helping you

even if you become sick or injured and cannot make decisions for yourself.

 Notary (or Notary Public): a person who is licensed by the State to witness signatures on

documents. You must sign your power of attorney document in front of a notary who will also

sign the document and place an official notary stamp on it.

 Personal Property: things like cash, stocks, jewelry, clothing, furniture or cars.

 Real Property: buildings and land.

 Revoke: to cancel.

 Rights of survivorship: a written agreement between people who own property together. The

agreement says when one co-owner dies, the other co-owner(s) automatically gets the property.

 Trust: a written agreement where money and property is owned by a trust and managed by one

person (trustee) for the benefit of another person or people (beneficiary or beneficiaries). Usually

you need to hire a lawyer to set up a trust.

 Trustee: the person who manages a trust.