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STATUTORY FORM POWER OF ATTORNEY THIS IS AN

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Power of Attorney, NRS 162A.620 (October 1
st
2019)
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.
Power of Attorney, NRS 162A.620 (October 1
st
2019)
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:
A. First Alternative Agent
Name: _______________________________________________________________
Address: _____________________________________________________________
Telephone Number: ____________________________________________________
B. Second Alternative Agent
Name: _______________________________________________________________
Address: _____________________________________________________________
Telephone Number: ____________________________________________________
Power of Attorney, NRS 162A.620 (October 1
st
2019)
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, proceedings seeking an adjudication of
incapacity 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.
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:
(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
[_____] 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
Power of Attorney, NRS 162A.620 (October 1
st
2019)
[_____] 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 authority to take actions that
could significantly reduce your property or change how your property is distributed at your
death. INITIAL ONLY the specific authority you WANT to give 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
[_____] Disclaim or refuse an interest in property, including a power of appointment
[_____] Consent to placement in an assisted living facility as defined in NRS 422.3962
[_____] Consent to placement in a facility for skilled nursing as defined in NRS 449.0039
[_____] Consent to placement in a secured residential long-term care facility as defined in
NRS 159.0255
Power of Attorney, NRS 162A.620 (October 1
st
2019)
7. EXPRESSION OF INTENT CONCERNING LIVING ARRANGEMENTS.
[_____] It is my intention to live in my home as long as it is safe and my medical needs can be
met. My agent may arrange for a natural person, employee of an agency or provider
of community-based services to come into my home to provide care for me. When it
is no longer safe for me to live in my home, I authorize my agent to place me in a
facility or home that can provide any medical assistance and support in my activities
of daily living that I require. Before being placed in such a facility or home, I wish for
my agent to discuss and share information concerning the placement with me.
[_____] It is my intention to live in my home for as long as possible without regard for my
medical needs, personal safety or ability to engage in activities of daily living. My
agent may arrange for a natural person, an employee of an agency or a provider of
community-based services to come into my home and provide care for me. I
understand that, before I may be placed in a facility or home other than the home in
which I currently reside, a guardian must be appointed for me.
[_____] I desire for my agent to take the following actions relating to my care:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
8. 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.
9. SPECIAL INSTRUCTIONS OR OTHER OR ADDITIONAL AUTHORITY GRANTED TO
AGENT:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Power of Attorney, NRS 162A.620 (October 1
st
2019)
10. AUTHORITY OF PRINCIPAL.
Except as otherwise expressly provided in this Power of Attorney, the authority of a principal to
act on his or her own behalf continues after executing this Power of Attorney and any decision or
instruction communicated by the principal supersedes any inconsistent decision or instruction
communicated by an agent appointed pursuant to this Power of Attorney.
11. 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:.....
12. 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.
13. 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.
Power of Attorney, NRS 162A.620 (October 1
st
2019)
14. 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 (date) _____________________________ at
(city) __________________________________, (state) ________________________________
(Signature) ________________________________
CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC
(You may use acknowledgment before a notary public instead of the statement of witnesses.)
State of Nevada }
}ss.
County of _____________________ }
On this _______ day of _______________, in the year _______, 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.
NOTARY SEAL _________________________________
(Signature of Notary Public)
Power of Attorney, NRS 162A.620 (October 1
st
2019)
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;
(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;
Power of Attorney, NRS 162A.620 (October 1
st
2019) - eForms
(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.
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Completed 2 November 2021

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