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I agree with Freqflyer. In planning things like that, you also really need a consult to find out what your rights and responsibilities are. And the attorney may have additional ideas that would benefit or protect you. You can't get that from trying to handle a legal matter on your own, imo.
And, you make select a form that does not meet the requirements for your state.  Even if they say it does, they could be wrong.  Laws change all the time.  It's really risky to go it on your own and end up with a document that doesn't serve the purpose. 
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What is your question? If you are looking for blank Power of Attorney form you can get them off the Internet. But I am not in favor of do-it-yourself when it comes to POA, as one missing word or one misplaced word could create havoc.

It is best to make an appointment with an Elder Law Attorney who can explain State laws, and who will recommend that other legal documents be drawn up. I assume if one doesn't have a POA, they also do not have a Will or a Medical Directive.
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