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Power of Attorney Questionnaire

Personal Details
Title (required)
Full Name (required)
Address (required)
Post Code (required)
Date of Birth (required)
Daytime Phone Number (required)
Mobile Phone Number
Email Address (required)

Family Details
Full Name of Partner/Spouse
Date of Birth
Children
Child 1
Child's Full Name
Child's Date of Birth
Child 2
Child's Full Name
Child's Date of Birth
Child 3
Child's Full Name
Child's Date of Birth
Additional Children
Names and Date of Births of Additional Children

Details of Attorney
Attorney's Full Name
Attorney's Address
Attorney's Post Code
Attorney's Relationship to You
Details of Second Attorney
Attorney's Full Name
Attorney's Address
Attorney's Post Code
Attorney's Relationship to You

Powers you wish to grant to the Attorney(s)
If you wish to appoint two attorneys do you want them to act together or independently of each other when dealing with your affairs?
Do you wish your attorney(s) to have general power to act on your behalf?
If no, what do you wish your Attorney(s) to do on your behalf?

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