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FOR OFFICE USE ONLY:
WALK-IN TIME__________ TIME FORM TURNED IN__________ TIME DOCS NOTARIZED__________

ID CARD SCREEN____ __

INTAKE CLERK__________________________________________________________ CMTIS_______ SPOA_______ AFFIDAVIT_______

POWER OF ATTORNEY WORKSHEET
FOR OFFICIAL USE ONLY – PRIVACY ACT SENSITIVE. Any misuse or unauthorized disclosure may result in both civil and criminal penalties.
PRIVACY ACT STATEMENT: AUTHORTY 5 U.S.C. 301 & 44 U.S.C. 3101 DOD ID NUMBER PRINCIPAL PURPOSE(S): Obtain personal information
to prepare legal document(s). ROUTINE USE (S): Information provided will be used by legal assistance personnel (attorneys, legalmen,
paralegals, and clerical staff) to prepare power(s) of attorney requested by the individual providing the information.
MANDATORY/VOLUNTARY DISCLOSURE, CONSEQUENCES OF REFUSAL T O DISCLOSE: Disclosure of DoD ID Number is voluntary and there
will be no adverse consequence from refusal to disclose; however, an individual may be requested