A statutory power of attorney is used to authorize someone to make or perform property
transactions for you in the event that you are no longer able to do so. In the absence of such a
document, you may need to have a conservator appointed by the court to make or perform such
transactions.

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 Power(s)
of Attorney.

The “Principal” is the person granting the power.

         Name of Principal: ___________________________________

One or more “Agents” are the person(s) who are granted the power to make transactions on your behalf.

 Name of Primary Agent:   ______________________________

 (The person who will have primary authority to make decisions on your behalf)

 Address:      _________________________________________

                      _________________________________________

 Relationship: _________________________________________

Do you want this person to have the authority to make gifts of your property (up to
$10,000 per year) to him or herself? ____ yes     ____ no
 

If the person named above is unavailable to make transactions on your behalf, you may want to
designate a back-up, or secondary, agent:
 

 Name of Secondary Agent: _____________________________

 Address:      _________________________________________

                      _________________________________________

 Relationship: _________________________________________

Do you want this person to have the authority to make gifts of your property (up to
$10,000 per year) to him or herself? ____ yes     ____ no