Checklist: general power of attorney and healthcare proxy

Data sheet for the preparation of the general power of attorney and healthcare proxy

1. principal (for spouses, please fill out principal 1 and 2)

Vollmachtgeber 1

Name

First name

Birth name

Date of birth

Birth place

Address (street, house no, post code, city)

Phone Number

E-Mail oder Telefax

Principal 2

Name

First name

Birth name

Date of birth

Birth place

Address (street, house no, post code, city)

Phone Number

E-Mail oder Telefax


2. Data proxies (at mutual empowerment, please write „see principal__”)

Bevollmächtigter 1

Name

First name

Birth name

Date of birth

Birth place

Address (street, house no, post code, city)

Phone Number

E-Mail oder Telefax

Relationship

Ranking ratio of the proxy

Proxy 2

Name

First name

Birth name

Date of birth

Birth place

Address (street, house no, post code, city)

Phone Number

E-Mail oder Telefax

Relationship

Ranking ratio of the proxy


Proxy 3

Name

First name

Birth name

Date of Birth

Birth place

Address (street, house no, post code, city)

Phone Number

E-Mail oder Telefax

Relationship

Ranking ratio of the proxy

Bevollmächtigter 4

Name

First name

Birth name

Date of birth

Birth place

Address (street, house no, post code, city)

Phone number

E-Mail oder Telefax

Relationship

Ranking ratio of the proxy


By submitting the checklist, you order a chargeable draft. Your completed checklist will be sent in PDF format to the email address notariat@notar-haas-sauer.de.

Your Email Address (*)
Additional notes