Personal Authorization Form

Personal Authorization Form

Please read and complete this form carefully to authorize another person or entity to act on your behalf.

Authorizing Party (Grantor) Information

Name

    Date of Birth

      Phone Number

        Email

          Address

            Authorized Party (Grantee) Information

            Name

              Relationship to Grantor

                Phone Number

                  Email

                    Address

                      Authorization Details

                      Purpose of Authorization

                        Effective Date

                          Expiration Date

                            Specific Powers Granted (if applicable)

                              Authorization Statement

                              I, [Your Name], hereby authorize to act on my behalf for the purposes outlined above. I understand that I may revoke this authorization at any time by providing written notice. Until such revocation, I understand that is authorized to act on my behalf.

                              Signature of Grantor

                              Name:

                              Date:

                              Witness Information (if required)

                              Name

                                Signature of Witness

                                Name:

                                Date:

                                By submitting this form, I confirm that I have read and understood the above authorization and grant the powers described herein.

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