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Address....
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Signature....
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Witness No. 2:
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(print) Name.... Date....
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Address....
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Signature....
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STATEMENT OF HEALTH CARE AGENT AND
17
ALTERNATE HEALTH CARE AGENT
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I understand that.... (name of principal) has designated me to be his or her
19health care agent or alternate health care agent if he or she is ever found to have
20incapacity and unable to make health care decisions himself or herself. .... (name of
21principal) has discussed his or her desires regarding health care decisions with me.
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Agent's signature....
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Address....
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Alternate's signature....
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Address....
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1Failure to execute a power of attorney for health care document under chapter
2155 of the Wisconsin Statutes creates no presumption about the intent of any
3individual with regard to his or her health care decisions.
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This power of attorney for health care is executed as provided in chapter 155
5of the Wisconsin Statutes.
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ANATOMICAL GIFTS (optional)
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Upon my death:
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.... I wish to donate only the following organs or parts: .... (specify the organs or
9parts).
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.... I wish to donate any needed organ or part.
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.... I wish to donate my body for anatomical study if needed.
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.... I refuse to make an anatomical gift. (If this revokes a prior commitment that
13I have made to make an anatomical gift to a designated donee, I will attempt to notify
14the donee to which or to whom I agreed to donate.)
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Failing to check any of the lines immediately above creates no presumption
16about my desire to make or refuse to make an anatomical gift.
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Signature.... Date....
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18Section
5. 244.41 (1) (i) of the statutes is created to read:
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244.41
(1) (i) Access the content of an electronic communication, as defined in
20s. 112.12 (2) (f), sent or received by the principal.
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21Section
6. 244.43 (9m) of the statutes is created to read:
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244.43
(9m) Access a catalogue of electronic communications, as defined in s.
23112.12 (2) (d), sent or received by the principal, and the principal's digital assets, as
24defined in s. 112.12 (2) (j), other than the content of electronic communications, as
25defined in s. 112.12 (2) (f)
.
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1Section
7. 244.61 (form) of the statutes is amended to read:
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2244.61 (form)
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3WISCONSIN STATUTORY FORM
4
POWER OF ATTORNEY
5
FOR FINANCES AND PROPERTY
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IMPORTANT INFORMATION
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THIS POWER OF ATTORNEY AUTHORIZES ANOTHER PERSON (YOUR
8AGENT) TO MAKE DECISIONS CONCERNING YOUR PROPERTY FOR YOU
9(THE PRINCIPAL). YOUR AGENT WILL BE ABLE TO MAKE DECISIONS AND
10ACT WITH RESPECT TO YOUR PROPERTY (INCLUDING YOUR MONEY)
11WHETHER OR NOT YOU ARE ABLE TO ACT FOR YOURSELF. THE MEANING
12OF AUTHORITY OVER SUBJECTS LISTED ON THIS FORM IS EXPLAINED IN
13THE UNIFORM POWER OF ATTORNEY FOR FINANCES AND PROPERTY ACT
14IN CHAPTER 244 OF THE WISCONSIN STATUTES.
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THIS POWER OF ATTORNEY DOES NOT AUTHORIZE THE AGENT TO
16MAKE HEALTH-CARE DECISIONS FOR YOU.
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YOU SHOULD SELECT SOMEONE YOU TRUST TO SERVE AS YOUR
18AGENT. UNLESS YOU SPECIFY OTHERWISE, GENERALLY THE AGENT'S
19AUTHORITY WILL CONTINUE UNTIL YOU DIE OR REVOKE THE POWER OF
20ATTORNEY OR THE AGENT RESIGNS OR IS UNABLE TO ACT FOR YOU.
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YOUR AGENT IS ENTITLED TO REASONABLE COMPENSATION
22UNLESS YOU STATE OTHERWISE IN THE SPECIAL INSTRUCTIONS.
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THIS FORM PROVIDES FOR DESIGNATION OF ONE AGENT. IF YOU
24WISH TO NAME MORE THAN ONE AGENT YOU MAY NAME A COAGENT IN
25THE SPECIAL INSTRUCTIONS. COAGENTS ARE NOT REQUIRED TO ACT
1TOGETHER UNLESS YOU INCLUDE THAT REQUIREMENT IN THE SPECIAL
2INSTRUCTIONS.
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IF YOUR AGENT IS UNABLE OR UNWILLING TO ACT FOR YOU, YOUR
4POWER OF ATTORNEY WILL END UNLESS YOU HAVE NAMED A
5SUCCESSOR AGENT. YOU MAY ALSO NAME A 2ND SUCCESSOR AGENT.
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THIS POWER OF ATTORNEY BECOMES EFFECTIVE IMMEDIATELY
7UNLESS YOU STATE OTHERWISE IN THE SPECIAL INSTRUCTIONS. THIS
8POWER OF ATTORNEY DOES NOT REVOKE ANY POWER OF ATTORNEY
9EXECUTED PREVIOUSLY UNLESS YOU SO PROVIDE IN THE SPECIAL
10INSTRUCTIONS.
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IF YOU REVOKE THIS POWER OF ATTORNEY, YOU SHOULD NOTIFY
12YOUR AGENT AND ANY OTHER PERSON TO WHOM YOU HAVE GIVEN A
13COPY. IF YOUR AGENT IS YOUR SPOUSE OR DOMESTIC PARTNER AND
14YOUR MARRIAGE IS ANNULLED OR YOU ARE DIVORCED OR LEGALLY
15SEPARATED OR THE DOMESTIC PARTNERSHIP IS TERMINATED AFTER
16SIGNING THIS DOCUMENT, THE DOCUMENT IS INVALID.
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IF YOU HAVE QUESTIONS ABOUT THE POWER OF ATTORNEY OR THE
18AUTHORITY YOU ARE GRANTING TO YOUR AGENT, YOU SHOULD SEEK
19LEGAL ADVICE BEFORE SIGNING THIS FORM.
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DESIGNATION OF AGENT
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I .... (name of principal) name the following person as my agent:
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Name of agent: ....
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Agent's address: ....
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Agent's telephone number: ....
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DESIGNATION OF SUCCESSOR AGENT(S) (OPTIONAL)
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1If my agent is unable or unwilling to act for me, I name as my successor agent:
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Name of successor agent: ....
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Successor agent's address: ....
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Successor agent's telephone number: ....
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If my successor agent is unable or unwilling to act for me, I name as my 2nd
6successor agent:
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Name of 2nd successor agent: ....
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Second successor agent's address: ....
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Second successor agent's telephone number: ....
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GRANT OF GENERAL AUTHORITY
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I grant my agent and any successor agent general authority to act for me with
12respect to the following subjects as defined in the Uniform Power of Attorney for
13Finances and Property Act in chapter 244 of the Wisconsin statutes:
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INITIAL each subject you want to include in the agent's general authority.
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.... Real property
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.... Tangible personal property
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.... Stocks and bonds
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.... Commodities and options
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.... Banks and other financial institutions
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.... Operation of entity or business
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.... Insurance and annuities
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.... Estates, trusts, and other beneficial interests
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.... Claims and litigation
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.... Personal and family maintenance
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.... Benefits from governmental programs or civil or military service
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1.... Retirement plans
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LIMITATION ON AGENT'S AUTHORITY
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An agent who is not my spouse or domestic partner MAY NOT use my property
5to benefit the agent or a person to whom the agent owes an obligation of support
6unless I have included that authority in the special instructions.
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7ACCESS TO DIGITAL ASSETS
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8If I have checked "Yes" to the following, my agent may access the content of
9electronic communications on my behalf. If I have checked "No" to the following, my
10agent may not access the content of electronic communications on my behalf.
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11Access to content of electronic communications — Yes.... No....
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12If I have not checked either "Yes" or "No" immediately above, my agent may not
13access the content of electronic communications on my behalf.
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SPECIAL INSTRUCTIONS (OPTIONAL)
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You may give special instructions in the following space ....
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EFFECTIVE DATE
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This power of attorney is effective immediately unless I have stated otherwise
18in the special instructions.
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NOMINATION OF GUARDIAN (OPTIONAL)
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If it becomes necessary for a court to appoint a guardian of my estate or
21guardian of my person, I nominate the following person(s) for appointment:
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Name of nominee for guardian of my estate: ....
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Nominee's address: ....
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Nominee's telephone number: ....
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Name of nominee for guardian of my person: ....
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1Nominee's address: ....
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Nominee's telephone number: ....
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RELIANCE ON THIS POWER OF
4
ATTORNEY FOR FINANCES AND PROPERTY
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Any person, including my agent, may rely upon the validity of this power of
6attorney or a copy of it unless that person knows that the power of attorney has been
7terminated or is invalid.