Your Information:

1. Insert your full name:
Surname:  
First name(s): 

2. Insert your address:

 Street: 

 City: 

 Province: 

 Postal Code: 

 Telephone Number (including area code): 

 E-mail Address: 

Attorneys:

3. Insert name of first attorney:  

4. Describe relationship of first attorney to you: 

5. If you wish, insert the name of second attorney. If none, skip to question 8.

 

6. If applicable, describe relationship of second attorney to you. If none, skip to question 8.

7. If you have chosen more than one attorney, do you wish each of them to be able to act independently (otherwise, all will be required to act together to carry out all acts for you).

  Yes No</FONT></FONT>

Substitute Attorneys:

8. If you wish, insert name of a substitute attorney who will act if any of the other attorneys is unable or unwilling to act. If none, skip to question 12.

 

9. If applicable, describe relationship of substitute attorney to you. If none, skip to
question 12.

10. If applicable, insert name of a second substitute attorney who will act if any of the other attorneys is unable or unwilling to act. If none, skip to question 12.

11. If applicable, describe relationship of second substitute attorney to you. If none, skip to question 12.

Conditions or Restrictions:

12. If you wish to insert any conditions or restrictions, insert them here. If not, skip to question 13.

Specific Instructions:

13. If you wish to insert any specific instructions, insert them here. If not, skip to
question 14. (By default, we have included an instruction that life support systems not be used; please read it carefully and then if you do not want this clause to be included, modify it as you wish or delete it entirely.)

If I am suffering from a terminal illness or injury from which there is no reasonable expectation of recovery, it is my wish that I be kept as comfortable as possible and that drugs be administered mercifully to alleviate pain, even if they hasten the moment ofdeath. I do notwish to be kept alive in these circumstances by artificial means or heroic measures. It is my expectation that artificial measures and heroic efforts will be used if medically necessary for short periods after surgery or treatments.

Compensation:

14. The compensation arrangement for my attorneys is (choose one):

All attorneys have agreed to perform their services under the power of attorney without compensation.

Attorneys are to be compensated in accordance with the fee schedule established by the Ontario Government.

The compensation arrangement I wish to have is:

Other Provisions:

15. If there are any other provisions you wish to add, set them out here:

16. If you have any questions not answered to your satisfaction by this Wizard , set them out here, or if you wish to speak with one of our lawyers in person or by telephone, indicate that here:

Payment instructions:

We accept payment by cheque payable to Hooey Remus, In Trust. Please send your cheque by Canada Post or delivery to 1 University Avenue, P.O. Box 40 Suite 400, Toronto, Ontario, Canada  M5J 2P1. We will deposit this cheque in our trust account and will begin to work on your power of attorney as soon as your cheque is received. Documents will be mailed to you as soon as your cheque has cleared our trust account (5 working days are required by Law Society regulations). We will not transfer these funds out of our trust account until we have completed your power of attorney.

 

Authorization:

I am 16 years of age or older. By inserting my name below, I authorize Hooey Remus to prepare a power of attorney for personal care for me based on the information provided and agree to pay for such services in accordance with the payment option I have chosen above.

Authorizing Name: 

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