Durable Power of Attorney
Affidavit
Account Information
First and Last Name of Account Owner
Account Number(s) Subject to Attorney-in-Fact Instructions (the “Account(s)”)
Attorney-in-Fact Information
First and Last Name of Attorney-in-Fact
Residential Address (P.O Box not acceptable)
Mailing Address (if different from Residential Address)
By signing below, you, as the Attorney-in-Fact of the Account Owner (“You” or “Your”), affirm that:
You are of legal age and mentally competent to act as Attorney-in-Fact.
You have previously been appointed by the Account Owner to act as Attorney-in-Fact over the Account(s),
and that Account Owner is not deceased, has not partially or totally revoked, suspended, or terminated the
authority delegated to You, and that there is no petition pending to determine the incapacity or to appoint a
guardian for the Account Owner.
You, as the Attorney-in-Fact, are authorized to perform the following acts on behalf of the Account Owner:
a) Execute documents for the Account(s) and issue instructions to Depository by regular mail,
facsimile or email;
b) Direct Depository to deposit, ship, transfer, or segregate Precious Metals Bullion for the Account(s);
c) Receive and view reports and information relating to the Account(s).
You will identify Yourself as Attorney-in-Fact when signing documents on behalf of the Account Owner,
using the following accepted form: "[Account Owner’s Name] by [Your signature] as Agent"
You have read, and that You understand and agree to be bound by, the provisions of this Affidavit, as well as
(and without limitation) the terms and conditions governing the Account(s) set forth in the Non‐Commercial
Depository Account Agreement, as is currently in effect and as may be amended in the future.
You will defend, indemnify and hold Depository harmless from and against any and all losses, liabilities,
claims, and costs (including reasonable attorneys’ fees) resulting from Your instructions to Depository.
You will promptly provide Depository with satisfactory written notice of either the Account Owner's death or
your removal or resignation as Attorney-in-Fact.
You will cease to give instructions to Depository as Attorney-in-Fact if you know, or have reason to know,
that Your capacity to act as Attorney-in-Fact has been limited or terminated for any reason.
You Understand that, in the event of any conflict between instructions given by Attorneys-in-Fact or by the
Account Owner and an Attorney-in-Fact, Depository may restrict the Account until it has received joint
written instructions that it finds satisfactory.
SIGNATURE OF ATTORNEY-IN-FACT: RETURN THIS COMPLETED AND SIGNED FORM TO:
X
Signature Date
Print Name & Title
Delaware Depository Services Company, LLC, 3601 North Market Street, Wilmington, DE 19802
T: (302) 765-3889 W: www.DelawareDepository.com E: ddsops@DelawareDepository.com F: (302) 762-2674
R151102
Delaware Depository
Attn: Operations Department
3601 North Market Street
Wilmington, DE 19802
