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State of Georgia }
County of ________________ }
STATUTORY FORM POWER OF ATTORNEY
IMPORTANT INFORMATION
This power of attorney authorizes another person (your agent) to make decisions concerning
your property for you (the principal). Your agent will be able to make decisions and act with
respect to your property (including your money) whether or not you are able to act for yourself.
The meaning of authority over subjects listed on this form is explained in O.C.G.A. Chapter 6B
of Title 10.
This power of attorney does not authorize the agent to make health care decisions for you.
You should select someone you trust to serve as your agent. Unless you specify otherwise in the
Special Instructions, generally the agent's authority will continue until you die or revoke the
power of attorney or the agent resigns or is unable to act for you.
Your agent is not entitled to any compensation unless you state otherwise in the Special
Instructions. Your agent shall be entitled to reimbursement of reasonable expenses incurred in
performing the acts required by you in your power of attorney.
This form provides for designation of one agent. If you wish to name more than one agent, you
may name a successor agent or name a co-agent in the Special Instructions. Co-agents will not be
required to act together unless you include that requirement in the Special Instructions.
If your agent is unable or unwilling to act for you, your power of attorney will end unless you
have named a successor agent. You may also name a second successor agent.
This power of attorney shall be durable unless you state otherwise in the Special Instructions.
This power of attorney becomes effective immediately unless you state otherwise in the Special
Instructions.
If you have questions about the power of attorney or the authority you are granting to your agent,
you should seek legal advice before signing this form.
DESIGNATION OF AGENT
I __________________________ (Name of principal) name the following person as my agent:
Name of agent: __________________________
Agent's address: __________________________
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Agent's telephone number: __________________________
Agent's e-mail address: __________________________
DESIGNATION OF SUCCESSOR AGENT(S) (OPTIONAL)
If my agent is unable or unwilling to act for me, I name as my successor agent:
Name of successor agent: __________________________
Successor agent's address: __________________________
Successor agent's telephone number: __________________________
Successor agent's e-mail address: __________________________
If my successor agent is unable or unwilling to act for me, I name as my second successor agent:
Name of second successor agent: __________________________
Second successor agent's address: __________________________
Second successor agent's telephone number: __________________________
Second successor agent's e-mail address: __________________________
GRANT OF GENERAL AUTHORITY
I grant my agent and any successor agent general authority to act for me with respect to the
following subjects as defined in O.C.G.A. Chapter 6B of Title 10:
(INITIAL each subject you want to include in the agent's general authority. If you wish to grant
general authority over all of the subjects you may initial "all preceding subjects" instead of
initialing each subject.)
_____ Real property
_____ Tangible personal property
_____ Stocks and bonds
_____ Commodities and options
_____ Banks and other financial institutions
_____ Operation of entity or business
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_____ Insurance and annuities
_____ Estates, trusts, and other beneficial interests
_____ Claims and litigation
_____ Personal and family maintenance
_____ Benefits from governmental programs or civil or military service
_____ Retirement plans
_____ Taxes
_____ All preceding subjects
GRANT OF SPECIFIC AUTHORITY (OPTIONAL)
My agent SHALL NOT do any of the following specific acts for me UNLESS I have
INITIALED the specific authority listed below:
(CAUTION: Granting any of the following will give your agent the authority to take actions that
could significantly reduce your property or change how your property is distributed at your
death. INITIAL ONLY the specific authority you WANT to give your agent. You should give
your agent specific instructions in the Special Instructions when you authorize your agent to
make gifts.)
_____ Create, fund, amend, revoke, or terminate an inter vivos trust
_____ Make a gift, subject to the limitations of O.C.G.A. § 10-6B-56 and any Special
Instructions in this power of attorney
_____ Create or change rights of survivorship
_____ Create or change a beneficiary designation
_____ Authorize another person to exercise the authority granted under this power of attorney
_____ Waive the principal's right to be a beneficiary of a joint and survivor annuity, including a
survivor benefit under a retirement plan
_____ Excise authority over the content of electronic communications sent or received by the
Principal
_____ Exercise fiduciary powers that the principal has authority to delegate and that are
expressly and clearly identified (including the persons for which the principal acts as a fiduciary)
in the Special Instructions
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_____ Renounce an interest in property, including a power of appointment
LIMITATION ON AGENT'S AUTHORITY
An agent that is not my ancestor, spouse, or descendant SHALL NOT use my property to benefit
the agent or a person to whom the agent owes an obligation of support unless I have included
that authority in the Special Instructions.
SPECIAL INSTRUCTIONS (OPTIONAL)
You may give special instructions on the following lines (you may add lines or place your
special instructions in a separate document and attach it to the power of attorney):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
EFFECTIVE DATE
This power of attorney is effective immediately unless I have stated otherwise in the Special
Instructions.
NOMINATION OF CONSERVATOR (OPTIONAL)
If it becomes necessary for a court to appoint a conservator of my estate, I nominate the
following person(s) for appointment:
Name of nominee for conservator of my estate: __________________________
Nominee's address: __________________________
Nominee's telephone number: __________________________
Nominee's e-mail address: __________________________
RELIANCE ON THIS POWER OF ATTORNEY
Any person, including my agent, may rely upon the validity of this power of attorney or a copy
of it unless that person has actual knowledge it has terminated or is invalid.
SIGNATURE AND ACKNOWLEDGMENT
Your signature __________________________ Date _________________________
Your name printed __________________________
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Your address __________________________
Your telephone number __________________________
Your e-mail address __________________________
This document was signed in my presence on __________________________, (Date) by
__________________________ (Name of principal)
Witness Signature __________________________
Witness's name printed __________________________
Witness's address __________________________
Witness's telephone number __________________________
Witness's e-mail address __________________________
State of Georgia }
County of ________________ }
This document was signed in my presence on __________________________ (Date) by
__________________________ (Name of principal).
(Seal)
Signature of notary __________________________
My commission expires __________________________
This document prepared by __________________________
IMPORTANT INFORMATION FOR AGENT
Agent's Duties
When you accept the authority granted under this power of attorney, a special legal relationship
is created between you and the principal. This relationship imposes upon you legal duties that
continue until you resign or the power of attorney is terminated or revoked. You must:
(1) Do what you know the principal reasonably expects you to do with the
principal's property or, if you do not know the principal's expectations, act
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in the principal's best interest;
(2) Act in good faith;
(3) Do nothing beyond the authority granted in this power of attorney; and
(4) Disclose your identity as an agent whenever you act for the
principal by writing or printing the name of the principal and signing your
own name as "agent" in the following manner:
__________________________ by __________________________ as Agent.
(Principal's name) (Your signature)
Unless the Special Instructions in this power of attorney state otherwise, you must also:
(1) Act loyally for the principal's benefit;
(2) Avoid conflicts that would impair your ability to act in the principal's best interest;
(3) Act with care, competence, and diligence;
(4) Keep a record of all receipts, disbursements, and transactions made on behalf of the principal;
(5) Cooperate with any person that has authority to make health care decisions for the principal
to do what you know the principal reasonably expects or, if you do not know the principal's
expectations, to act in the principal's best interest; and
(6) Attempt to preserve the principal's estate plan if you know the plan and preserving the plan is
consistent with the principal's best interest.
Termination of Agent's Authority
You must stop acting on behalf of the principal if you learn of any event that terminates this
power of attorney or your authority under this power of attorney. Events that terminate a power
of attorney or your authority to act under a power of attorney include:
(1) Death of the principal;
(2) The principal's revocation of your authority or the power of attorney
(3) The occurrence of a termination event stated in the power of attorney;
(4) The purpose of the power of attorney is fully accomplished; or
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(5) If you are married to the principal, a legal action is filed with a court to end your marriage, or
for your legal separation, unless the Special Instructions in this power of attorney state that such
an action will not terminate your authority.
Liability of Agent
The meaning of the authority granted to you is defined in O.C.G.A. Chapter 6B of Title 10. If
you violate O.C.G.A. Chapter 6B of Title 10 or act outside the authority granted, you may be
liable for any damages caused by your violation.
If there is anything about this document or your duties that you do not understand, you should
seek legal advice.
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