State Law. This Power of Attorney is governed by the laws of the State of
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Signed this ____ day of _______________________, 20___.
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Signature
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Print Name
ACCEPTANCE OF APPOINTMENT
I, ________________________, the attorney-in-fact named above, hereby accept
appointment as attorney-in-fact in accordance with the foregoing instrument.
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Attorney-in-Fact’s Signature
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Attorney-in-Fact’s Printed Name
WITNESSES
We, the witnesses, each do hereby declare in the presence of the principal that the
principal signed and executed this instrument as his Power of Attorney in the presence of
each of us, that he signed it willingly, that each of us hereby signs this Power of Attorney
as witness at the request of the principal and in his presence, and that, to the best of our
knowledge, the principal is eighteen years of age or over, of sound mind, and under no
constraint or undue influence.
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Witness Signature Address
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Witness Print Name City, State & Zip Code
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Witness Signature Address
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Witness Print Name City, State & Zip Code