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.

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    Additional notes