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POWER OF ATTORNEY NEW YORK STATUTORY SHORT FORM

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Page 1 of 7
POWER OF ATTORNEY
NEW YORK STATUTORY SHORT FORM
(a) CAUTION TO THE PRINCIPAL: Your Power of Attorney is an important document.
As the "principal," you give the person whom you choose (your "agent") authority to
spend your money and sell or dispose of your property during your lifetime without
telling you. You do not lose your authority to act even though you have given your agent
similar authority.
When your agent exercises this authority, he or she must act according to any
instructions you have provided or, where there are no specific instructions, in your best
interest. "Important Information for the Agent" at the end of this document describes
your agent's responsibilities.
Your agent can act on your behalf only after signing the Power of Attorney before a
notary public. You can request information from your agent at any time. If you are
revoking a prior Power of Attorney, you should provide written notice of the revocation
to your prior agent(s) and to any third parties who may have acted upon it, including the
financial institutions where your accounts are located.
You can revoke or terminate your Power of Attorney at any time for any reason as long
as you are of sound mind. If you are no longer of sound mind, a court can remove an
agent for acting improperly.
Your agent cannot make health care decisions for you. You may execute a "Health Care
Proxy" to do this.
The law governing Powers of Attorney is contained in the New York General Obligations
Law, Article 5, Title 15. This law is available at a law library, or online through the New
York State Senate or Assembly websites, www.nysenate.gov or www.nyassembly.gov.
If there is anything about this document that you do not understand, you should ask a
lawyer of your own choosing to explain it to you.
(b) DESIGNATION OF AGENT(S):
I, ______________________, with a mailing address of ______________________,
City of ______________________, State of New York, hereby appoint:
______________________, with a mailing address of ______________________, City
of ______________________, State of New York as my agent.
INITIAL ONE (1)
_____ - There shall be no other Agents.
_____ - There shall be another Agent known as ______________________, with a
mailing address of ______________________, City of ______________________,
State of New York as my agent.
Page 2 of 7
If you designate more than one agent above, and you do not initial the statement below,
they must act together.
_____ - My agents may act SEPARATELY.
(c) DESIGNATION OF SUCCESSOR AGENT(S): (OPTIONAL) (INITIAL)
_____ - There shall be no Successor Agents.
_____ - There shall be a Successor Agent known as ______________________, with a
mailing address of ______________________, City of ______________________,
State of New York.
_____ - There shall be a Successor Agent known as ______________________, with a
mailing address of ______________________, City of ______________________,
State of New York.
If you do not initial the statement below, successor agents designated above must act
together.
_____ - My Successor Agents may act SEPARATELY.
You may provide for specific succession rules in this section. Insert specific succession
provisions here: ________________________________________________________
(d) THIS POWER OF ATTORNEY shall not be affected by my subsequent incapacity
unless I have stated otherwise below, under "Modifications".
(e) THIS POWER OF ATTORNEY DOES NOT REVOKE any Powers of Attorney
previously executed by me unless I have stated otherwise below, under "Modifications."
(f) GRANT OF AUTHORITY:
To grant your agent some or all of the authority below, either
(1) Initial the bracket at each authority you grant, or (2) Write or type the letters for each
authority you grant on the blank line at (P), and initial the bracket at (P). If you initial (P),
you do not need to initial the other lines.
I grant authority to my agent(s) with respect to the following subjects as defined in
sections 5-1502A through 5-1502N of the New York General Obligations Law:
_____ - (A) real estate transactions;
_____ - (B) chattel and goods transactions;
_____ - (C) bond, share, and commodity transactions;
Page 3 of 7
_____ - (D) banking transactions;
_____ - (E) business operating transactions;
_____ - (F) insurance transactions;
_____ - (G) estate transactions;
_____ - (H) claims and litigation;
_____ - (I) personal and family maintenance. If you grant your agent this authority, it will
allow the agent to make gifts that you customarily have made to individuals, including
the agent, and charitable organizations. The total amount of all such gifts in any one
calendar year cannot exceed five hundred dollars;
_____ - (J) benefits from governmental programs or civil or military service;
_____ - (K) health care billing and payment matters; records, reports, and statements;
_____ - (L) retirement benefit transactions;
_____ - (M) tax matters;
_____ - (N) all other matters;
_____ - (O) full and unqualified authority to my agent(s) to delegate any or all of the
foregoing powers to any person or persons whom my agent(s) select;
_____ - (P) EACH of the matters identified by the following letters _________________.
You need not initial the other lines if you initial line (P).
(g) CERTAIN GIFT TRANSACTIONS: STATUTORY GIFTS RIDER (OPTIONAL)
In order to authorize your agent to make gifts in excess of an annual total of $5,000 for
all gifts described in (I) of the grant of authority section of this document (under personal
and family maintenance), and/or to make changes to interest in your property, you must
expressly grant that authorization in the Modifications section below. If you wish to
authorize your agent to make gifts to himself or herself, you must expressly grant such
authorization in the Modifications section below. Granting such authority to your agent
gives your agent the authority to take actions which could significantly reduce your
property and/or change how your property is distributed at your death. Your choice to
grant such authority should be discussed with a lawyer.
_____ - I grant my agent authority to make gifts in accordance with the terms and
conditions of the Modifications that supplement this Statutory Power of Attorney.
Page 4 of 7
(h) MODIFICATIONS: (OPTIONAL)
In this section, you may make additional provisions, including, but not limited to,
language to limit or supplement authority granted to your agent, language to grant your
agent the specific authority to make gifts to himself or herself, and/or language to grant
your agent the specific authority to make other gift transactions and/or changes to
interests in your property. Your agent is entitled to be reimbursed from your assets for
reasonable expenses incurred on your behalf. In this section, you may make additional
provisions if you ALSO wish your agent(s) to be compensated from your assets for
services rendered on your behalf, and you may define “reasonable compensation.”
______________________________________________________________________
(i) DESIGNATION OF MONITOR(S): (OPTIONAL)
If you wish to appoint monitor(s), initial and fill in the section below:
_____ - I wish to designate ______________________, whose address(es) is (are)
____________________________________________________________, as
monitor(s). Upon the request of the monitor(s), my agent(s) must provide the monitor(s)
with a copy of the power of attorney and a record of all transactions done or made on
my behalf. Third parties holding records of such transactions shall provide the records
to the monitor(s) upon request.
(j) COMPENSATION OF AGENT(S):
Your agent is entitled to be reimbursed from your assets for reasonable expenses
incurred on your behalf. If you ALSO wish your agent(s) to be compensated from your
assets for services rendered on your behalf, and/or you wish to define “reasonable
compensation”, you may do so above, under “Modifications”.
(k) ACCEPTANCE BY THIRD PARTIES: I agree to indemnify the third party for any
claims that may arise against the third party because of reliance on this Power of
Attorney. I understand that any termination of this Power of Attorney, whether the result
of my revocation of the Power of Attorney or otherwise, is not effective as to a third
party until the third party has actual notice or knowledge of the termination.
(l) TERMINATION: This Power of Attorney continues until I revoke it or it is terminated
by my death or other event described in section 5-1511 of the General Obligations Law.
Section 5-1511 of the General Obligations Law describes the manner in which you may
revoke your Power of Attorney, and the events which terminate the Power of Attorney.
(m) SIGNATURE AND ACKNOWLEDGMENT:
In Witness Whereof I have hereunto signed my name on __________________, 20___.
PRINCIPAL’S SIGNATURE __________________________________________
Page 5 of 7
STATE OF NEW YORK
COUNTY OF _______________________
On the ____ day of __________________ in the year 20___ before me, the
undersigned notary public, personally appeared _______________________,
personally known to me or proved to me on the basis of satisfactory evidence to be the
individual(s) whose name(s) is (are) subscribed to the within instrument and
acknowledged to me that he/she/they executed the same in his/her/their capacity(ies),
and that by his/her/their signature(s) on the instrument, the individual(s), or the person
upon behalf of which the individual(s) acted, executed the instrument.
____________________________________
Notary Public Signature
(n) SIGNATURES OF WITNESSES:
By signing as a witness, I acknowledge that the principal signed the Power of Attorney
in my presence and in the presence of the other witness, or that the principal
acknowledged to me that the principal's signature was affixed by him or her or at his or
her direction. I also acknowledge that the principal has stated that this Power of
Attorney reflects his or her wishes and that he or she has signed it voluntarily. I am not
named herein as an agent or as a permissible recipient of gifts.
____________________________ ____________________________
Signature of Witness 1 Signature of Witness 2
____________________________ ____________________________
Date Date
____________________________ ____________________________
Print Name Print Name
____________________________ ____________________________
Address Address
____________________________ ____________________________
City, State, Zip Code City, State, Zip Code
This document prepared by: _______________________________________________
(o) IMPORTANT INFORMATION FOR THE AGENT:
When you accept the authority granted under this Power of Attorney, a special legal
relationship is created between you and the principal. This relationship imposes on you
legal responsibilities that continue until you resign or the Power of Attorney is
terminated or revoked. You must:
(1) act according to any instructions from the principal, or, where there are no
instructions, in the principal's best interest;
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(2) avoid conflicts that would impair your ability to act in the principal's best interest;
(3) keep the principal's property separate and distinct from any assets you own or
control, unless otherwise permitted by law;
(4) keep a record of all transactions conducted for the principal or keep all receipts of
payments and transactions conducted for the principal; and
(5) disclose your identity as an agent whenever you act for the principal by writing or
printing the principal's name and signing your own name as "agent" in either of the
following manners: (Principal's Name) by (Your Signature) as Agent, or (your signature)
as Agent for (Principal's Name).
You may not use the principal's assets to benefit yourself or anyone else or make gifts
to yourself or anyone else unless the principal has specifically granted you that authority
in the modifications section of this document or a Non-Statutory Power of Attorney. If
you have that authority, you must act according to any instructions of the principal or,
where there are no such instructions, in the principal's best interest. You may resign by
giving written notice to the principal and to any co-agent, successor agent, monitor if
one has been named in this document, or the principal's guardian if one has been
appointed. If there is anything about this document or your responsibilities that you do
not understand, you should seek legal advice.
Liability of Agent:
The meaning of the authority given to you is defined in New York's General Obligations
Law, Article 5, Title 15. If it is found that you have violated the law or acted outside the
authority granted to you in the Power of Attorney, you may be liable under the law for
your violation.
(p) AGENT'S SIGNATURE AND ACKNOWLEDGMENT OF APPOINTMENT:
It is not required that the principal and the agent(s) sign at the same time, nor that
multiple agents sign at the same time.
I/we, ___________________________________________, have read the foregoing
Power of Attorney. I am/we are the person(s) identified therein as agent(s) for the
principal named therein.
I/we acknowledge my/our legal responsibilities.
In Witness Whereof I have hereunto signed my name on ________________ 20_____.
Agent(s) Signature __________________________________________
Agent(s) Signature __________________________________________
Page 7 of 7
STATE OF NEW YORK
COUNTY OF _______________________
On the ____ day of __________________ in the year 20___ before me, the
undersigned notary public, personally appeared _______________________,
personally known to me or proved to me on the basis of satisfactory evidence to be the
individual(s) whose name(s) is (are) subscribed to the within instrument and
acknowledged to me that he/she/they executed the same in his/her/their capacity(ies),
and that by his/her/their signature(s) on the instrument, the individual(s), or the person
upon behalf of which the individual(s) acted, executed the instrument.
____________________________________
Notary Public
(q) SUCCESSOR AGENT'S SIGNATURE AND ACKNOWLEDGMENT OF
APPOINTMENT:
It is not required that the principal and the SUCCESSOR agent(s), if any, sign at the
same time, nor that multiple SUCCESSOR agents sign at the same time. Furthermore,
successor agents cannot use this power of attorney unless the agent(s) designated
above is/are unable or unwilling to serve.
I/we, ___________________________________________, have read the foregoing
Power of Attorney. I am/we are the person(s) identified therein as SUCCESSOR
agent(s) for the principal named therein.
In Witness Whereof I have hereunto signed my name on ________________ 20_____.
Successor Agent(s) Signature ______________________________________
Successor Agent(s) Signature ______________________________________
STATE OF NEW YORK
COUNTY OF _______________________
On the ____ day of __________________ in the year 20___ before me, the
undersigned notary public, personally appeared _______________________,
personally known to me or proved to me on the basis of satisfactory evidence to be the
individual(s) whose name(s) is (are) subscribed to the within instrument and
acknowledged to me that he/she/they executed the same in his/her/their capacity(ies),
and that by his/her/their signature(s) on the instrument, the individual(s), or the person
upon behalf of which the individual(s) acted, executed the instrument.
____________________________________
Notary Public
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Completed 24 June 2021

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