Illinois Power of Attorney Template
This Power of Attorney ("POA") document is created pursuant to the Illinois Power of Attorney Act (755 ILCS 45/). It grants the person you choose (your "Agent") the power to act on your behalf in matters that you specify below. Please complete the following information accurately to ensure this document meets your needs.
Principal Information
- Full Name: ___________________________________
- Address: _____________________________________
- City: _______________, State: Illinois, Zip Code: _________
- Phone Number: ________________________________
Agent Information
- Full Name: ___________________________________
- Address: _____________________________________
- City: _______________, State: _______________, Zip Code: _________
- Phone Number: ________________________________
Alternate Agent (Optional)
In the event the original Agent is unable or unwilling to serve, an alternate Agent can be named. This is optional.
- Full Name: ___________________________________
- Address: _____________________________________
- City: _______________, State: _______________, Zip Code: _________
- Phone Number: ________________________________
Powers Granted
Select the powers you wish to grant to your Agent by initialing next to each applicable power.
- ____ Real Property Transactions
- ____ Financial Institution Transactions
- ____ Personal and Family Maintenance
- ____ Health Care Decisions (including consent to any medical treatment)
- ____ Business Operating Transactions
- ____ Insurance and Annuity Transactions
- ____ Estate, Trust, and other Beneficiary Transactions
- ____ Claims and Litigation
- ____ Tax Matters
- ____ Social Security, Employment and Military Service Benefits
- ____ All other matters (to specify): ________________________________
Effective Date and Duration
This Power of Attorney shall become effective on the date of _______________ and, unless revoked earlier, will continue until _______________.
Signature of Principal
By signing below, I confirm that I understand and agree to the terms of this Power of Attorney.
_______________________________________
Signature of Principal
Date: _______________
Signature of Agent
By signing below, I accept my appointment as Agent under this Power of Attorney.
_______________________________________
Signature of Agent
Date: _______________
Witness Declaration
This Power of Attorney was signed in the presence of the undersigned witnesses, who affirm that the Principal appeared to understand the purpose of the document and was free from duress or undue influence at the time of signing.
- Witness #1 Signature: _____________________________________
- Name: ___________________________________________________
- Date: _______________
- Witness #2 Signature: _____________________________________
- Name: ___________________________________________________
- Date: _______________
Notarization (if required)
This section should be completed by a Notary Public if notarization is required or desired for added legal formality.
State of Illinois )
County of ___________ )
On ______________________ (date), before me, ________________________ (Notary’s name), personally appeared ________________________ (Name of Principal), known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that they executed the same for the purposes therein contained.
In witness whereof, I hereunto set my hand and official seal.
_______________________________________
Notary Public
My Commission Expires: _______________