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Notary
Fields of activity
Forms
Arrival
Contact

805_Manuel_Busch_logo_LH

+49 2234 946780

info@notar-busch.de

EN

EN DE ZH

Online form for general and health care proxy

We would like to implement your power of attorney quickly and legally. You can support us by filling out this form. Even a partial completion is already a great help to us.

I. Information about the principal

Number of principals

Mutual authorization of the principals

Yes

No

Principal 1

Salutation * / Title

first name(s)

Last name

Maiden name if applicable

birth date

DD

MM

YYYY

Place of birth

Address

Street Address ZIP / Postal Code City

Other contact options

E-mail

phone

e-mail

phone

interpreter required

Yes

No

Interpreter required for which language?

Physically restricted

Yes

No

What physical limitations do you have?

Principal 2

Salutation * / Title

first name(s)

Last name

Maiden name if applicable

birth date

DD

MM

YYYY

Place of birth

Address

Street Address ZIP / Postal Code City

Other contact options

E-mail

phone

e-mail

phone

interpreter required

Yes

No

Interpreter required for which language?

Physically restricted

Yes

No

What physical limitations do you have?

II. Details of other authorized persons

II. Details of the authorized persons

Number of authorized persons

Number of other authorized persons

Other authorized person 1

Authorized person 1

Salutation * / Title

first name(s)

Last name

Maiden name if applicable

birth date

DD

MM

YYYY

Address

Street Address ZIP / Postal Code City

Other contact options

E-mail

phone

e-mail

phone

Authorized by

Principal 1

Principal 2

Other authorized person 2

authorized person 2

Salutation * / Title

first name(s)

Last name

Maiden name if applicable

birth date

DD

MM

YYYY

Address

Street Address ZIP / Postal Code City

Other contact options

E-mail

phone

e-mail

phone

Authorized by

Principal 1

Principal 2

Other authorized person 3

Authorized person 3

Salutation * / Title

first name(s)

Last name

Maiden name if applicable

birth date

DD

MM

YYYY

Address

Street Address ZIP / Postal Code City

Other contact options

E-mail

phone

e-mail

phone

Authorized by

Principal 1

Principal 2

Other authorized person 4

Authorized person 4

Salutation * / Title

first name(s)

Last name

Maiden name if applicable

birth date

DD

MM

YYYY

Address

Street Address ZIP / Postal Code City

Other contact options

E-mail

phone

e-mail

phone

Authorized by

Principal 1

Principal 2

III. Power of Attorney Information

Should the authorized representatives be in a rank relationship?

Yes

No

Which rank ratio is desired?

spouse before children

Miscellaneous

Desired Rank Ratio

Should the powers of the authorized representatives be comprehensive?

Yes (usually)

No (exceptional case)

Limitation of Powers

Personal Care Restriction

Limitation on property care

Other Restriction

Other Limitation of Powers

Is the principal involved in companies?

Yes

No

Company name / stake

Should a living will be certified in the same appointment?

Yes. I will prepare these myself and bring them with me to the appointment.

Yes. I would like the notary to send a sample living will.

No

Would you like to be registered in the central pension register?

Yes (usually)

No

IV. Notes/Other Notices

Comments / non-binding appointment requests

Filler's name(Required)

Contact(Required)

E-mail

phone

post

E-mail of the person completing the form(Required)

Telephone number of the person completing the form(Required)

Postal address of the person completing the form

Street Address ZIP / Postal Code City

commissioning(Required)

I instruct the notary to prepare the certification of the power of attorney. I am aware that the creation of a draft will incur costs, even if it is not notarized.

Draft to principal

by email

by post

Draft to principal 1

by email

by post

Draft to principal 2

by email

by post

data protection(Required)

I have the Privacy Policy had read.

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Notary's office Manuel Busch | Richard-Wagner-Strasse 1-3 | 50859 Cologne

Notary office Manuel Busch
Richard-Wagner-Strasse 1-3
50859 Cologne

+49 2234 946780

info@notar-busch.de