Fill - Free fillable KENTUCKY LIMITED POWER OF ATTORNEY FORM I. NOTICE PDF form

KENTUCKY

LIMITED POWER OF ATTORNEY FORM

I. NOTICE - This legal document grants you (Hereinafter referred to as the

“Principal”) the right to transfer limited financial powers to someone else

(Hereinafter referred to as the “Attorney-in-Fact”), limited financial powers

are described as: any specific financial act legal under law. The Principal’s

transfer of limited financial powers to the Attorney-in-Fact are granted upon

authorization of this agreement, and ONLY remains in effect until the

completion of said act, unless the Principal becomes incapacitated

(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 Limited 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 Limited Power of Attorney Form, it will revoke any

previously valid Limited Power of Attorney Form.

II. INCAPACITATION – The powers granted to the Attorney-in-Fact by the

Principal in this Limited 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 Limited Power of

Attorney Form at anytime. Any revocation will be effective if the Principal:

A. Authorizes a new Limited Power of Attorney Form.

B. Authorizes a Power of Attorney Revocation Form.

IV. WITNESS & NOTARY - This document is not valid as a Limited 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

Limited Power of Attorney Form notarized.

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 a specific financial act

or acts immediately upon the authorization of this form, and I grant the power

to act as if I were personally present to

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 for a specific financial act on my

behalf that can be any power legal under law in the State of

_________________________. The Specific financial act I grant my Attorney-in-

State

Fact is:

____________________________________________________________________

A Detailed Description of Exact Powers granted

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 for a specific financial act on my

behalf that can be any power legal under law in the State of

_________________________. The Specific financial act I grant my Successor

State

Attorney-in-Fact is:

____________________________________________________________________

A Detailed Description of Exact Powers granted

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

Limited 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

XII. PRINCIPAL’S SIGNATURE - I, _________________________, the

Printed Name of Principal

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

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signature

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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

XIV. 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 and 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

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

!

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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