Fillable STATUTORY FORM POWER OF ATTORNEY

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STATUTORY FORM POWER OF ATTORNEY

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STATUTORY FORM POWER OF ATTORNEY
THIS IS AN IMPORTANT LEGAL DOCUMENT. IT CREATES A DURABLE
POWER OF ATTORNEY FOR FINANCIAL MATTERS. BEFORE EXECUTING THIS
DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:
1. THIS DOCUMENT GIVES THE PERSON YOU DESIGNATE AS YOUR
AGENT THE POWER TO MAKE DECISIONS CONCERNING YOUR PROPERTY
FOR YOU. 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.
2. THIS POWER OF ATTORNEY BECOMES EFFECTIVE IMMEDIATELY
UNLESS YOU STATE OTHERWISE IN THE SPECIAL INSTRUCTIONS.
3. THIS POWER OF ATTORNEY DOES NOT AUTHORIZE THE AGENT TO
MAKE HEALTH CARE DECISIONS FOR YOU.
4. THE PERSON YOU DESIGNATE IN THIS DOCUMENT HAS A DUTY TO
ACT CONSISTENT WITH YOUR DESIRES AS STATED IN THIS DOCUMENT OR
OTHERWISE MADE KNOWN OR, IF YOUR DESIRES ARE UNKNOWN, TO ACT
IN YOUR BEST INTERESTS.
5. 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.
6. YOUR AGENT IS ENTITLED TO REASONABLE COMPENSATION UNLESS
YOU STATE OTHERWISE IN THE SPECIAL INSTRUCTIONS.
7. THIS FORM PROVIDES FOR DESIGNATION OF ONE AGENT. IF YOU WISH
TO NAME MORE THAN ONE AGENT YOU MAY NAME A CO-AGENT IN THE
SPECIAL INSTRUCTIONS. CO-AGENTS ARE NOT REQUIRED TO ACT
TOGETHER UNLESS YOU INCLUDE THAT REQUIREMENT IN THE SPECIAL
INSTRUCTIONS.
8. 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.
9. YOU HAVE THE RIGHT TO REVOKE THE AUTHORITY GRANTED TO THE
PERSON DESIGNATED IN THIS DOCUMENT.
10. THIS DOCUMENT REVOKES ANY PRIOR DURABLE POWER OF
ATTORNEY.
11. IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT
UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.
‐1‐
1. DESIGNATION OF AGENT:
I, ______________________ (insert your name) do hereby designate and appoint:
Name: ______________________
Address: ____________________________________________
Telephone Number: ______________________
as my agent to make decisions for me and in my name, place and stead and for my use and
benefit and to exercise the powers as authorized in this document.
2. DESIGNATION OF ALTERNATE AGENT.
(You are not required to designate any alternative agent but you may do so. Any
alternative agent you designate will be able to make the same decisions as the agent
designated above in the event that he or she is unable or unwilling to act as your agent.
Also, if the agent designated in paragraph 1 is your spouse, his or her designation as your
agent is automatically revoked by law if your marriage is dissolved.)
If my agent is unable or unwilling to act for me, then I designate the following
person(s) to serve as my agent as authorized in this document, such person(s) to serve in
the order listed below:
3. OTHER POWERS OF ATTORNEY.
This Power of Attorney is intended to, and does, revoke any prior Power of Attorney
for financial matters I have previously executed.
4. NOMINATION OF GUARDIAN.
If, after execution of this Power of Attorney, incompetency proceedings are initiated
either for my estate or my person, I hereby nominate as my guardian or conservator for
consideration by the court my agent herein named, in the order named.
‐2‐
A. First Alternative Agent
Name: ______________________
Address: ____________________________________________
Telephone Number: ______________________
B. Second Alternative Agent
Name: ______________________
Address: ____________________________________________
Telephone Number: ______________________
5. GRANT OF GENERAL AUTHORITY.
I grant my agent and any successor agent(s) general authority to act for me with respect
to the following subjects:
(YOU SHOULD INITIAL EACH SUBJECT THAT YOU WANT TO INCLUDE IN THE
AGENT’S GENERAL AUTHORITY. IF YOU WISH TO GRANT GENERAL
AUTHORITY OVER ALL OF THE FOLLOWING SUBJECTS, YOU MAY INITIAL
JUST THE LAST ENTRY, ENTITLED “ALL PRECEEDING SUBJECTS”, INSTEAD
OF INITIALING EACH SUBJECT):
[____] Real Property
[____] Tangible Personal Property
[____] Stocks and Bonds
[____] Commodities and Options
[____] Banks and Other Financial Institutions
[____] Safe Deposit Boxes
[____] Operation of Entity or Business
[____] Insurance and Annuities
[____] Estates, Trusts and Other Beneficial Interests
[____] Legal Affairs, Claims and Litigation
[____] Personal Maintenance
[____] Benefits from Governmental Programs or Civil or Military Service
[____] Retirement Plans
[____] Taxes
[____] All Preceding Subjects
6. GRANT OF SPECIFIC AUTHORITY.
My agent MAY NOT do any of the following specific acts for me UNLESS I have
INITIALED the specific authority listed below:
(CAUTION: GRANTING ANY OF THE FOLLOWING WILL GIVE YOUR AGENT
THE AUTHRORITY TO TAKE ACTIONS THAT COULD SIGNIFICANTLY REDUCE
YOUR PROPERTY OR CAHNGE HOW YOUR PROPERTY IS DISTRIBUTED AT
YOUR DEATH. INITIAL ONLY THE SPECIFIC AUTHORITY YOU WANT TO
GIVE TO YOUR AGENT.)
[____] Create, amend, revoke or terminate an inter vivos, family, living, irrevocable or
revocable trust
[____] Make a gift, subject to the limitations of NRS and any special instructions in this
Power of Attorney
[____] Create or change rights of survivorship
[____] Create or change a beneficiary designation
[____] Waive the principal’s right to be a beneficiary of a joint and survivor annuity,
including a survivor benefit under a retirement plan
[____] Exercise fiduciary powers that the principal has authority to delegate
‐3‐
[____] Disclaim or refuse an interest in property, including a power of appointment
7. LIMITATION ON AGENT’S AUTHORITY.
An agent that is not my spouse MAY NOT use my property to benefit the agent or a
person to whom the agent owes an obligation of support unless I have included that
authority in the Special Instructions.
8. SPECIAL INSTRUCTIONS OR OTHER OR ADDITIONAL AUTHORITY
GRANTED TO AGENT:
9. DURABILITY AND EFFECTIVE DATE. (INITIAL THE CLAUSE(S) THAT
APPLIES.)
[____] DURABLE. This Power of Attorney shall not be affected by my subsequent
disability or incapacity.
[____] SPRINGING POWER. It is my intention and direction that my designated agent,
and any person or entity that my designated agent may transact business with on my
behalf, may rely on a written medical opinion issued by a licensed medical doctor stating
that I am disabled or incapacitated, and incapable of managing my affairs, and that said
medical opinion shall establish whether or not I am under a disability for the purpose of
establishing the authority of my designated agent to act in accordance with this Power of
Attorney.
[____] I wish to have this Power of Attorney become effective on the following date: .....
[____] I wish to have this Power of Attorney end on the following date: .....
10. THIRD PARTY PROTECTION.
Third parties may rely upon the validity of this Power of Attorney or a copy and the
representations of my agent as to all matters relating to any power granted to my agent, and
no person or agency who relies upon the representation of my agent, or the authority
granted by my agent, shall incur any liability to me or my estate as a result of permitting
my agent to exercise any power unless a third party knows or has reason to know this
Power of Attorney has terminated or is invalid.
11. RELEASE OF INFORMATION.
I agree to, authorize and allow full release of information, by any government agency,
business, creditor or third party who may have information pertaining to my assets or
income, to my agent named herein.
12. SIGNATURE AND ACKNOWLEDGMENT. YOU MUST DATE AND SIGN THIS
POWER OF ATTORNEY. THIS POWER OF ATTORNEY WILL NOT BE VALID
UNLESS IT IS ACKNOWLEDGED BEFORE A NOTARY PUBLIC.
I sign my name to this Power of Attorney on ____________________, 20____ (date)
at ____________________ (city), ____________________ (state)
‐4‐
____________________________________
(Your Signature Here)
CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC
(You may use acknowledgment before a notary public instead of the statement of
witnesses.)
}
}ss.
State of Nevada
County of ____________________ }
On this ____day of ____________________, in the year 20____, before me,
____________________ (here insert name of notary public) personally appeared
____________________ (here insert name of principal) personally known to me
(or proved to me on the basis of satisfactory evidence) to be the person whose name is
subscribed to this instrument, and acknowledged that he or she executed it. I declare under
penalty of perjury that the person whose name is ascribed to this instrument appears to be
of sound mind and under no duress, fraud or undue influence.
NOTARY SEAL _____________________________
(Signature of Notary Public)
IMPORTANT INFORMATION FOR AGENT
1. 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. This
relationship imposes upon you legal duties that continue until you resign or the Power of
Attorney is terminated or revoked. You must:
(a) 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;
(b) Act in good faith;
(c) Do nothing beyond the authority granted in this Power of Attorney; and
(d) 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
2. Unless the Special Instructions in this Power of Attorney state otherwise, you must
also:
(a) Act loyally for the principal’s benefit;
(b) Avoid conflicts that would impair your ability to act in the principal’s best interest;
‐5‐
(c) Act with care, competence, and diligence;
(d) Keep a record of all receipts, disbursements and transactions made on behalf of the
principal;
(e) 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; and
(f) 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.
3. Termination of Agent’s Authority. You must stop acting on behalf of the principal
if you learn of any event that terminates 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:
(a) Death of the principal;
(b) The principal’s revocation of the Power of Attorney or your authority;
(c) The occurrence of a termination event stated in the Power of Attorney;
(d) The purpose of the Power of Attorney is fully accomplished; or
(e) If you are married to the principal, your marriage is dissolved.
4. Liability of Agent. The meaning of the authority granted to you is defined in NRS
162A.200 to 162A.660, inclusive. If you violate NRS 162A.200 to 162A.660, inclusive, or
act outside the authority granted in this Power of Attorney, you may be liable for any
damages caused by your violation.
5. If there is anything about this document or your duties that you do not understand,
you should seek legal advice.
‐6‐
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Completed 2 November 2021

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