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NORTH CAROLINA STATUTORY SHORT FORM POWER OF ATTORNEY

NOTICE: THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD AND SWEEPING. THEY ARE DEFINED IN CHAPTER

32C OF THE NORTH CAROLINA GENERAL STATUTES, WHICH EXPRESSLY PERMITS THE USE OF ANY OTHER OR DIFFER-

ENT FORM OF POWER OF ATTORNEY DESIRED BY THE PARTIES CONCERNED.

IMPORTANT INFORMATION

is 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. e meaning of authority over subjects listed on this form is explained in the North Carolina Uniform Power of Attorney Act.

is 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, 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 Additional Provisions and Exclusions.

is form provides for designation of one agent, a successor agent, and a second successor agent. If you wish to name more than one

agent, successor agent, and second successor agent, you may name a coagent, successor coagent, or second successor coagent in the Ad-

ditional Provisions and Exclusions. Coagents, successor coagents, or second successor coagents are not required to act together unless

you include that requirement in the Additional Provisions and Exclusions.

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.

is power of attorney becomes eective immediately.

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 the following person as my agent:

(Name of Principal)

Name of Agent: ____________________________________________________________

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: ______________________________________________________

If my successor agent is unable or unwilling to act for me, I name as my second successor agent:

Name of Second Successor Agent: ________________________________________________

INITIAL below if you want to give an agent the power to name a successor agent.

(____) I give to my acting agent the full power to appoint another to act as my agent, and full power to revoke such appointment, if no agent

named by me above is willing or able to act.

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 dened in the North Carolina

Uniform Power of Attorney Act, Chapter 32C of the General Statutes:

(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

(____)

Insurance and Annuities

(____)

Estates, Trusts, and Other Benecial Interests

(____)

Claims and Litigation

(____)

Personal and Family Maintenance

(____)

Benets from Governmental Programs or Civil or Military Service

(____)

Retirement Plans

(____)

Taxes

(____)

All Preceding Subjects

GRANT OF SPECIFIC AUTHORITY (OPTIONAL)

Even if you have given your agent general authority to act on your behalf, your agent MAY NOT do any of the following specic acts for you

UNLESS you expressly authorize it. If you wish your agent to have that additional authority, you should INITIAL only those additional specic

authorities you WANT to give your agent.

(CAUTION: Granting any of the following will give your agent the authority to take actions that could signicantly reduce

your property or change how your property is distributed at your death. INITIAL ONLY those specic authorities you

WANT to give your agent.)

In addition to the General Authority I have given my agent, I expressly authorize my agent to do the following specic acts:

(____)

Make a gi, subject to the limitations provided in G.S. 32C-2-217

(____)

Create or change rights of survivorship

(____)

Create or change a beneciary designation

(____)

Authorize another person to exercise the authority granted under this power of attorney

(____)

Waive my right to be a beneciary of a joint and survivor annuity, including a survivor benet under a retirement plan

(____)

Exercise duciary powers that I have authority to delegate

(____)

Disclaim or refuse an interest in property, including a power of appointment

(____)

Access the content of electronic communications

TRANSACTIONS THAT BENEFIT AGENT OR PERSONS TO WHOM AGENT OWES OBLIGATION OF SUPPORT

Unless you expressly authorize it, your agent MAY NOT exercise authority under this power of attorney if the exercise of that authority benets

the agent or a person to whom the agent owes an obligation of support. You should INITIAL below ONLY if you WANT to give your agent that

authority.

(____) My agent MAY exercise authority under this power of attorney to benet my agent or any person to whom my agent owes an obliga-

tion of support.

ADDITIONAL PROVISIONS AND EXCLUSIONS (OPTIONAL)

(____) ________________________________________________________________________

________________________________________________________________________

EFFECTIVE DATE

is power of attorney is eective immediately.

NOMINATION OF GUARDIAN (OPTIONAL)

INITIAL below ONLY if you WANT your acting agent to be your Guardian.

(____) If it becomes necessary for a court to appoint a guardian of my estate or a general guardian, I nominate my agent acting under this

power of attorney to be the guardian to serve without bond or other security.

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.

MEANING AND EFFECT

e meaning and eect of this power of attorney shall for all purposes be determined by the law of the State of North Carolina.

SIGNATURE AND ACKNOWLEDGEMENT

_____________________________________ ________________________

Your Signature Date

_____________________________________

Your Name Printed

State of ______________________, County of _______________________

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signature

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I certify that the following person personally appeared before me this day, acknowledging to me that he or she signed the forego-

ing document: ___________________________________.

Date: __________________ _______________________________________

Signature of Notary Public

(Ocial Seal)

___________________________, Notary Public

Printed or typed name

My commission expires: __________________

ND: 4827-5005-2940, v. 1

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.

is relationship imposes upon you legal duties that continue until you resign or your authority is terminated 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 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: (Principal’s Name) by (Your Signature) as Agent.

Unless the Additional Provisions and Exclusions in this power of attorney state otherwise, you must also:

1. Act loyally for the principal’s benet;

2. Avoid conicts 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;

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; and

7. Account to the principal (or a person designated by the principal (if any)) in the Additional Provisions and Exclusions.

Termination of Agent’s Authority

You must stop acting on behalf of the principal if you learn of any event that terminated or revoked 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. e principal’s revocation of the power of attorney or the termination of your authority;

3. e occurrence of a termination event stated in the power of attorney;

4. e purpose of the power of attorney is fully accomplished;

5. If you are married to the principal, your divorce from the principal, unless the Additional Provisions and Exclusions in this power

of attorney state that your divorce from the principal will not terminate your authority; or

6. A guardian of the principal’s estate or the principal’s general guardian revokes the power of attorney or terminates your authority.

Liability of Agent

e meaning of the authority granted to you is dened in the North Carolina Uniform Power of Attorney Act as set forth in Chapter 32C of

the North Carolina General Statutes. If you violate the North Carolina Uniform Power of Attorney Act 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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NORTH CAROLINA STATUTORY SHORT FORM POWER OF ATTORNEY

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