Power Of Attorney

Battle Creek: 693 Capital Avenue SW, Unit #3 Battle Creek, MI 49015

Kalamazoo: 2323 Gull Rd, SuiteA, Kalamazoo, MI 49048

Office Phone: (269) 963-3253, toll free (866) 963-3253

Fax Number: (269) 966-2485
Trust-Power of Attorney REFERRAL FORM
Directions:
1. In order to ensure a faster processing time, please complete this form completely.
2. The client intake/discharge specialist will contact you with any additional questions. A decision will not be made on the referral without all requested information.
3. As the petitioner, you will be contacted with the referral outcome. It is your responsibility to inform the appropriate parties of this decision. It is also your responsibility to ensure that Guardian Finance and Advocacy Services is provided with the date/time of the court hearing.
4. Please be aware that Guardian Finance and Advocacy Services reserves the right to decline a referral based upon the individuals situation and/or the capacity of Guardian Finance and Advocacy Services at the time of your request.

Information of Person Making the Referral
Person Referring*

First NameLast Name
Relationship/Agency
Phone Number*

Area CodePhone Number
E-mail*
How did you hear about us?
Services Requested (Please check all that apply):*

Power of Attorney (POA)TrusteeApply for SSA11
Trust Type
Current SSA Payee
Why would you like to resign as current fiduciary?
Reason for Referral*

Financials

Family and Interested Party Information
List all family members giving their relationship, name, address, and telephone numbers
Are any family members or interested parties attempting to become guardian for the Individual? If yes, please describe why a third party is being contacted.
THIS REFERRAL IS VALID FOR 6 MONTHS, AFTER

THAT PERIOD, A NEW APPLICATION IS REQUIRED
Should be Empty:

Trust-Power of Attorney REFERRAL FORM