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IMPORTANT INFORMATION This power of attorney authorizes another

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DURABLE 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.
This power of attorney does not authorize the agent to make medical and health care decisions for you.
You should select someone you trust to serve as your agent. Unless you specify otherwise, 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 entitled to reasonable compensation unless you state otherwise in the Special Instructions.
This form provides for designation of one agent. If you wish to name more than one agent you may name
a co-agent in the Special Instructions. Co-agents are not 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 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, ________________________ of ________________________________________ [Address],
authorize ________________________ of ________________________________________ [Address],
as my agent (attorney-in-fact) to act for me and in my name and for my use and benefit. If my agent is
unable or unwilling to act for me, I name ________________________ of
________________________________________ [Address] as my successor agent.
GRANT OF GENERAL AUTHORITY
I grant my agent and any successor agent general authority to act for me with respect to the following
subjects:
INITIAL each subject you want to include in the agent’s general authority.
INITIAL the line in front of “(N) All Preceding Subjects” if you wish to grant general authority over all of the
subjects instead of initialing each subject.
_______ (A) Real property
_______ (B) Tangible personal property
_______ (C) Stocks and bonds
_______ (D) Commodities and options
_______ (E) Banks and Other Financial Institutions
_______ (F) Operation of Entity or Business
_______ (G) Insurance and Annuities
_______ (H) Estates, Trusts, and Other Beneficiary Interests
_______ (I) Claims and Litigation
_______ (J) Personal and Family Maintenance
_______ (K) Benefits from Governmental Programs or Civil or Military Service
_______ (L) Retirement Plans
_______ (M) Taxes
_______ (N) All Preceding Subjects
GRANT OF SPECIFIC AUTHORITY (OPTIONAL)
My agent may 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.
_______ (A) Create, amend, revoke, or terminate an inter vivos trust
_______ (B) Make a gift
_______ (C) Create or change rights of survivorship
_______ (D) Create or change a beneficiary designation
_______ (E) Authorize another person to exercise the authority granted under this power of
attorney
_______ (F) Waive the principal’s right to be a beneficiary of a joint and survivor annuity,
including a survivor benefit under a retirement plan
_______ (G) Exercise fiduciary powers that the principal has authority to delegate
LIMITATION ON AGENT’S AUTHORITY
An agent that is not my ancestor, spouse, or descendant may 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:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
EFFECTIVE DATE
This power of attorney is effective immediately unless I have stated otherwise in the Special Instructions.
TERMINATION
This power of attorney shall not be affected by my subsequent disability or incapacity, or lapse of time.
NOMINATION OF GUARDIAN (OPTIONAL)
If it becomes necessary for a court to appoint a guardian of my estate or my person, I nominate the
following person(s) for appointment:
Name of Nominee for guardian of my estate: _________________________________________
Nominee’s Address: _____________________________________________________________
Nominee’s Telephone Number: ____________________________________________________
Name of Nominee for guardian of my person: ________________________________________
Nominee’s Address: _____________________________________________________________
Nominee’s Telephone Number: ____________________________________________________
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 knows it has terminated or is invalid.
SIGNATURE AND ACKNOWLEDGMENT
____________________________________ _______________
Signature of Principal Date
____________________________________
Name Printed
__________________________________________________________________________
Address
____________________________________
Telephone Number
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State/Commonwealth of _________________
County of _________________
On this ______ day of _______________, 20______, before me, ________________________,
personally appeared ________________________, personally known to me or who proved to me on the
basis of satisfactory evidence to be the person whose name is subscribed to this instrument and
acknowledged to me that he/she executed the same and that by his/her signature on this instrument the
person executed this instrument.
_____________________________________ (Seal, if any)
Signature of Notary
My commission expires: __________________
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Completed 16 March 2022

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