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Washington Financial Durable Power of Attorney Form

In Washington, should an individual elect someone as her/his official representative in financial affairs, said individual must fulfill this form.Download

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S	ENIOR 	R	IGHTS 	A	SSISTANCE	 
 
 
 	
GENERAL DURABLE POWER OF 
ATTORNEY 
(RCW 11.94) 
Effective Either Immediately  
or Upon Disability 
 
 
Before using this form, please read “Questions and 
Answers on Powers of Attorney” by Columbia Legal 
Services. The following document describes the use 
of durable powers of attorney for financial matters 
primarily. The contents of this form are suggested by 
Washington State statute, but an estate planning 
attorney can give you more detailed information and 
can help you tailor such documents to your specific 
needs.  
 
Powers	
 
 
Carefully note which powers you want to give to your 
agent, which are listed in Section 1.  Mark any 
powers you wish to give by putting your initials in the 
space in front of the numbered paragraph.  To make 
clear that you do not wish to give your agent that 
power, simply cross out that paragraph and initial 
next to it.

You can use this document to give someone both 
your financial and medical durable powers of 
attorney.  If you do not wish to make someone your 
medical/health care agent, cross out Paragraph 1. B 
and initial next to it. 
 
When Does the Durable Power of Attorney Go into 
Effect? 	 
 
Once signed, this document can go into effect in 
three different situations:  Immediately; When the 
Agent certifies that the Principal can’t make 
decisions independently; or When the Principal’s 
doctor certifies that the Principal can’t make 
decisions. You will want to think about when you 
want your agent to begin acting on your behalf, and 
mark the form accordingly.  To mark the form, put 
your initials in the space in front of the numbered 
paragraph. An Agent, sometimes referred to as the 
Attorney-in-Fact is the person exercising your power 
of attorney; the person to whom you are giving 
specific authority to act on your behalf. 
 
In all cases, you  should chose your agent carefully; 
they should be someone who will act carefully and 
prudently; they will be held to the highest standard of 
good faith, fair dealing and undivided loyalty with 
respect to you and your property. The person 
designated as agent should of course agee to the 
duties of agent before they are appointed as your 
agent.  And you can always revoke their 
appointment.   
 
The durable power of attorney can be effective 
immediately or not, depending on which paragraph in 
Section 2. A. is chosen by the person signing the  
power of attorney form, known as “The Principal”.

Effective Immediately	
 
 
If you want the power of attorney to go into effect 
immediately enabling your agent to begin to act on 
your behalf right away, then initial paragraph 1 in 
Section 2 part A.  This doesn’t mean that you lose 
control over your affairs, but rather that the person 
you have chosen to be your agent can now exercise 
the powers you gave them in case you need them to.   
 
Effective upon Disability	
 
 
If you want the power of attorney to go into effect 
when your agent certifies that you have become 
incapacitated and can no longer make important 
decisions independently, then initial paragraph 2 in 
Section 2 part A.  If you choose this option, you will 
be authorizing your agent to consult with your doctor 
or medical provider to gather the medical information 
they need to make this decision.  You will be signing 
a medical release as part of the form. 
 
If you want to have your doctor, or two doctors who 
have examined you, decide whether you are 
incapacitated, before the power of attorney can go 
into effect, then initial paragraph 3 in Section 2 part 
A.  This also includes a medical release.  
 
If you initial Section 2. A. paragraph 2 or 3, your 
agent won’t be able to use this document until the 
certification you specified is signed.  If you want your 
agent to be able to use the powers in the document 
immediately, then you should initial paragraph 1 so 
that it is effective immediately.

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: _______________________________________
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