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To save time and money before legal help, also consider appointing someone at least 20 years younger than you so that the possibility the person remains comptent. You will need to ask that person.
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I assume you want this for yourself? Best choice is an estate pallnign or elder law attorney, who can tailor it to your specific concerns and needs. Unless you have legal experience, don't get one online and fill it out.

You'll need to identify who you want to act as your proxy, so discuss that with that person and make sure both of you understand what's involved.

The attorney will provide a notary and witnesses from his/her staff.

This is NOT a DIY project.
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