PROFESSIONALS Please list any individuals and organizations entrusted with your current or future care. These are not necessarily the same people listed as family and personal contacts on p. 7. Your professionals would include professionals or groups responsible for your personal legal, financial and physical health, such as doctors, attorneys, CPA/accountants, insurance agents, financial advisors, trustee, personal representative, attorney-in-fact, healthcare surrogate, etc.
Choice of Personal Representative Personal Representative: Address: Phone: Email: Alternate: Address: Phone: Email:
Choice of Trustee Trustee: Address: Successor Trustee: Address:
Choice of Healthcare Surrogate/Attorney-in-Fact Healthcare Surrogate: Address: Phone: Email: Alternate: Address: Phone: Email: General Durable Power of Attorney: Address: Phone: Email: Alternate: Address: Phone: Email:
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