DPA Health Care

REQUEST FOR DURABLE POWER OF ATTORNEY FOR HEALTH CARE

After submission of the below-requested, information, you will be contacted
to schedule a telephone or in-office conference. In that conference, your
questions, if any, will be answered; and additional information will be
requested so that we may be prepare proper documents to meet your specific
needs. Arrangements for signing your final documents will also be made at
that time.

1. Your Information:

Name as you sign legal documents

Other name(s) in which you own assets:

Date of Birth: Birth State or Country:

Employed?: Retired?: US Citizen?: Gender:

Mailing Address City:

State: Zip Residence County:

Home phone: Work/Cell Phone:

Email:

2. Marriage Information:

Marital Status:

If currently married, where were you married? City State

Country: Marriage Date:

If widowed or divorced: Former Spouse's name:

Date of death or dissolution of marriage:

3. Spouse Information:

Name as you sign legal documents

Other name(s) in which you own assets:

Date of Birth: Birth State or Country:

Employed?: Retired?: US Citizen?: Gender:

Mailing Address City:

State: Zip Residence County:

Home phone: Work/Cell Phone:

Email:

1. Your Advance Health Care Agents

Agents Full Name (include full address if not previously provided) Relationship

If married, first agent will be Spouse: Agents will serve:

2. Spouse/Partner Advance Health Care Agents

Agents Full Name (include full address if not previously provided) Relationship

If married, first agent will be Spouse: Agents will serve:

Comments/Questions:

* CONFIRMATION*
I/We have confirmed that all spelling and personal information is correct. I/We further confirm that the wishes identified in the contents of this Client Information Form are my true wishes and desires and that I/we make these decisions without undue influence or duress. I/We Agree *If you do not understand, or have questions about this form, please contact us before submitting.*

Menke Law Firm, APC
5000 E. Spring St., #405, Long Beach, CA 90815
Phone (562) 496-4300 Fax (562) 496-4500