Fillable KENTUCKY GENERAL POWER OF ATTORNEY FORM I. NOTICE

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KENTUCKY GENERAL POWER OF ATTORNEY FORM I. NOTICE

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KENTUCKY
GENERAL POWER OF ATTORNEY FORM
I. NOTICE - This legal document grants you (Hereinafter referred to as the
“Principal”) the right to transfer unlimited financial powers to someone else
(Hereinafter referred to as the “Attorney-in-Fact”), unlimited financial powers
are described as: all financial decision making power legal under law. The
Principal’s transfer of financial powers to the Attorney-in-Fact are granted
upon authorization of this agreement, and DO NOT stay in effect in the event
of incapacitation by the Principal (incapacitation is described in Paragraph II).
This agreement does not authorize the Attorney-in-Fact to make medical
decisions for the Principal. The Principal continues to retain every right to all
their financial decision making power and may revoke this General Power of
Attorney Form at anytime. The Principal may include restrictions or requests
pertaining to the financial decision making power of the Attorney-in-Fact. It is
the intent of the Attorney-in-Fact to act in the Principal’s wishes put forth, or,
to make financial decisions that fit the Principal’s best interest. All parties
authorizing this agreement must be at least 18 years of age and acting under
no false pressures or outside influences. Upon authorization of this General
Power of Attorney Form, it will revoke any previously valid General Power of
Attorney Form.
II. INCAPACITATION – The powers granted to the Attorney-in-Fact by the
Principal in this General Power of Attorney Form DO NOT stay in effect upon
incapacitation by the Principal, incapacitation is describes as: A medical
physician stating verbally or in writing that the Principal can no longer make
decisions for them self.
III. REVOCATION - The Principal has the right to revoke this General Power of
Attorney Form at anytime. Any revocation will be effective if the Principal
either:
A. Authorizes a new General Power of Attorney Form.
B. Authorizes a Power of Attorney Revocation Form.
IV. WITNESS & NOTARY - This document is not valid as a General Power of
Attorney unless it is acknowledged before a notary public or is signed by at
least two adult witnesses who are present when the Principal signs or
acknowledges the Principal’s signature. It is recommended to have this
General Power of Attorney Form notarized.
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V. PRINCIPAL - I, ______________________, residing at
Name of Principal
_________________________________________________________________
Street Address of Principal
City of ______________________, State of ______________________, appoint
City of Principal State of Principal
the following as my Attorney-in-Fact, whom I trust with any and all my
financial decision making power immediately upon the authorization of this
form:
VI. ATTORNEY-IN-FACT - ______________________, residing at
Name of Attorney-in-Fact
_________________________________________________________________
Street Address of Attorney-in-Fact
City of ______________________, State of ______________________ grant
City of Attorney-in-Fact State of Attorney-in-Fact
the Attorney-in-Fact the legal authority to act on my behalf for any power legal
under law in regard to my financial decisions under the State of
_________________________.
State
VII. SUCCESSOR ATTORNEY-IN-FACT (Optional) – If the Attorney-in-Fact named
above cannot or is unwilling to serve, then I appoint ______________________,
Name of Successor Attorney-in-Fact
residing at
_________________________________________________________________
Street Address of Successor Attorney-in-Fact
City of ______________________, State of ______________________ grant
City of Successor Attorney-in-Fact State of Successor Attorney-in-Fact
the Attorney-in-Fact the legal authority to act on my behalf for any power legal
under law in regard to my financial decisions under the State of
_________________________.
State
VIII. TERMS & CONDITIONS – Upon authorization by all parties, the Attorney-in-
Fact accepts their designation to act in the Principal’s best interests for all
financial decisions legal under law.
IX. THIRD PARTIES – I, the Principal, agree that any third party receiving a
copy via: physical copy, email, or fax that I, the Principal, will indemnify and
hold harmless any and all claims that may be put forth in reference to this
Durable Power of Attorney Form.
X. COMPENSATION – The Attorney-in-Fact agrees not to be compensated for
acting in the presence of the Principal. The Attorney-in-Fact may be, but not
entitled to, reimbursement for all: food, travel, and lodging expenses for
acting in the presence of the Principal.
XI. DISCLOSURE - I intend for my attorney-in-fact under this Power of Attorney
to be treated, as I would be with respect to my rights regarding the use and
disclosure of my individually identifiable health information or other medical
records. This release authority applies to any information governed by the
Health Insurance Portability and Accountability Act of 1996 (aka HIPAA), 42 USC
1320d and 45 CFR 160-164
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XII. PRINCIPAL’S SIGNATURE - I, _________________________, the Principal,
Printed Name of Principal
sign my name to this power of attorney this ________ day of
Day
_________________________ and, being first duly sworn, do declare to the
Month
undersigned authority that I sign and execute this instrument as my power of
attorney and that I sign it willingly, or willingly direct another to sign for me,
that I execute it as my free and voluntary act for the purposes expressed in the
power of attorney and that I am eighteen years of age or older, of sound mind
and under no constraint or undue influence.
_________________________
Signature of Principal
XIII. ATTORNEY-IN-FACT’S SIGNATURE - I, ______________________________
Name of Attorney-in-Fact
have read the attached power of attorney and am the person identified as the
attorney-in-fact for the principal. I hereby acknowledge and accept my
appointment as Attorney-in-Fact and that when I act as agent I shall exercise
the powers for the benefit of the principal; I shall keep the assets of the
principal separate from my assets; I shall exercise reasonable caution and
prudence; and I shall keep a full and accurate record of all actions, receipts
and disbursements on behalf of the principal.
____________________________________ ______________________________
Signature of Attorney-in-Fact Date
SUCCESSOR ATTORNEY-IN-FACT’S SIGNATURE (Optional) -
I, ______________________________ have read the attached power of
Name of successor Attorney-in-Fact
attorney and am the person identified as the successor attorney-in-fact for the
principal. I hereby acknowledge that I accept my appointment as Successor
Attorney-in-Fact and that, in the absence of a specific provision to the contrary
in the power of attorney, when I act as agent I shall exercise the powers for
the benefit of the principal; I shall keep the assets of the principal separate
from my assets; I shall exercise reasonable caution and prudence; and I shall
keep a full and accurate record of all actions, receipts, and disbursements on
behalf of the principal.
______________________________ ______________________________
Signature of Successor Attorney-in-Fact Date
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Notary Acknowledgement (Must be completed by Notary)
State of ___________ County of ______________________________ Subscribed,
Sworn and acknowledged before me by ______________________________, the
Principal, and subscribed and sworn to before me by ______________________,
witness, this ______________________ day of ________________________.
______________________________
Notary Signature
Notary Public
In and for the County of ______________________________
State of ______________________________
My commission expires: ______________________________ Seal
Acknowledgement and Acceptance of Appointment as Attorney-in-Fact
I, ______________________________ have read the attached power of attorney
Name of Attorney-in-Fact
and am the person identified as the attorney-in-fact for the principal. I hereby
acknowledge that accept my appointment as Attorney-in-Fact and that when I
act as agent I shall exercise the powers for the benefit of the principal; I shall
keep the assets of the principal separate from my assets; I shall exercise
reasonable caution and prudence; and I shall keep a full and accurate of all
actions, receipts and disbursements on behalf of the principal.
______________________________ ______________________________
Signature of Attorney-in-Fact Date
Acceptance of Appointment as successor Attorney-in-Fact
I, ______________________________ have read the attached power of
Name of successor Attorney-in-Fact
attorney and am the person identified as the successor attorney-in-fact for the
principal. I hereby acknowledge that I accept my appointment as Successor
Attorney-in-Fact and that, in the absence of a specific provision to the contrary
in the power of attorney, when I act as agent I shall exercise the powers for
the benefit of the principal; I shall keep the assets of the principal separate
from my assets; I shall exercise reasonable caution and prudence; and I shall
keep a full and accurate record of all actions, receipts, and disbursements on
behalf of the principal.
______________________________ ______________________________
Signature of Successor Attorney-in-Fact Date
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Witness Attestation
I, ______________________, the first witness, and I ______________________
Printed Name of First Witness Printed Name of Second Witness
the second witness, sign my name to the foregoing power of attorney being
first duly sworn and do not declare to the undersigned authority that the
principal signs and executed this instrument as him or her, and that I, in the
presence and hearing of the principal, sign this power of attorney as witness to
the principal’s signing and that to the best of my knowledge the principal is
eighteen years of age or older, of sound mind and under no constraint or undue
influence.
______________________________ ______________________________
Signature of First Witness Signature of Second Witness
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KENTUCKY GENERAL POWER OF ATTORNEY FORM I. NOTICE

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Completed 20 December 2021

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