Your Name: __________________________    Telephone No. ___________________
Address: __________________________________________________________________

When you have completed this questionnaire, please return it to Gary C. Dahle - Attorney at
Law, at the above address, together with a check in the amount of $75.00 payable to Gary C.
Dahle - Attorney at Law, as a deposit towards the legal fees involved in preparing the
Health Care Declaration(s).

The “Principal” is the person granting the power.
     Name of Principal: ___________________________________
     Date of Birth: ________________________________________
     Address: _________________________________________

One or more “Agents” are the person(s) who are granted the power to make decisions for you.
     Name of Primary Agent: ______________________________
     (The person who will have primary authority to make decisions on your behalf)
     Address: _________________________________________
                     _________________________________________
     Phone Number: _____________________________________
     Relationship: (if any) _________________________________

If the person I have named above is unable, unavailable, or unwilling to make health care
decisions for me, I would like the following person to be my agent for making such
decisions:
     Name of Secondary Agent: _____________________________
     Address: _________________________________________
     Phone Number: _____________________________________
     Relationship: (if any) _________________________________