Fillable Special Power of Attorney (California)

Fill Online, Printable, Fillable, Blank Special Power of Attorney (California) Form

Use Fill to complete blank online CALIFORNIA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Special Power of Attorney (California)

On average this form takes 22 minutes to complete

The Special Power of Attorney (California) form is 5 pages long and contains:

  • 0 signatures
  • 11 check-boxes
  • 81 other fields

Country of origin: US
File type: PDF

BROWSE CALIFORNIA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
PERS-OSS-138 (12/18) Page 1 of 5
Section 2
Designation of Attorney-in-Fact (Agent)
When completing this form,
please be sure to print the
requested information.
For the purpose of this
form, a “principal” is
defined as a person who
empowers another to act
as a representative on
his or her behalf.
The “agent” is the
attorney-in-fact.
If you appoint more than
one attorney-in-fact and do
not check a box, all of your
attorneys-in-fact must act
or sign together (jointly).
*If you choose “Alternately,”
identify the order of
your attorneys-in-fact in
the boxes below.
Name of Principal (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Address County
City State ZIP Daytime Phone
By this document I intend to create a power of attorney by appointing the person(s) named below to make
retirement-related decisions for me as allowed by the California Probate Code. The authority granted
pursuant to this power of attorney is expressly limited to decisions relating to my financial and health
benefits under the California Public Employees’ Retirement System, the Judges’ Retirement System I or the
Judges’ Retirement System II, and the Legislators’ Retirement System, hereinafter CalPERS, JRS I, JRS II,
and LRS, respectively. I give my agent, also called an attorney-in-fact, the powers specified herein with
the understanding that these powers will be used for my benefit and will be exercised only in a fiduciary
capacity. This power does not authorize the appointed agent to make any medical decisions for me.
Section 1
Creation of Durable Power of Attorney for Retirement-Related Business
You have the option to designate one attorney-in-fact. Your attorney-in-fact must be at least 18 years
old at the time this document is executed.
If you appoint more than one attorney-in-fact, choose the jointly, separately, or alternately check box below:
c
Jointly – All designated attorneys-in-fact must sign for any action. Granting joint authority to two or
more attorneys-in-fact means that the agents’ authority is exercisable only by their unanimous action.
If one is unavailable because of absence, illness, or other temporary incapacity, the other attorneys-in-
fact may exercise their authority under the power of attorney.
c
Separately – Any one designated attorney-in-fact may act without the other(s).
c
Alternately – Your attorney-in-fact will act in the numerical order you assign in the boxes below.*
The successor attorney-in-fact will act if the person you originally appointed is unavailable because
of absence, illness, or other temporary incapacity. Delegation of powers to any third party who is not
named as an alternate attorney-in-fact is not permitted under this document.
( )
( )
( )
( )
Name of Attorney-in-Fact (First Name, Middle Initial, Last Name) Birth Date (mm/dd/yyyy) Relationship
Address Social Security Number or CalPERS ID
City State ZIP Daytime Phone
Name of Attorney-in-Fact (First Name, Middle Initial, Last Name) Birth Date (mm/dd/yyyy) Relationship
Address Social Security Number or CalPERS ID
City State ZIP Daytime Phone
Name of Attorney-in-Fact (First Name, Middle Initial, Last Name) Birth Date (mm/dd/yyyy) Relationship
Address Social Security Number or CalPERS ID
City State ZIP Daytime Phone
#
#
#
Special Power of Attorney
888 CalPERS (or 888-225-7377)
•
TTY: (877) 249-7442
PERS-OSS-138 (12/18) Page 2 of 5
You must check a box
to indicate whether
you are granting the
specific authority to your
attorney(s)-in-fact. If you
do not check a box, your
attorney(s)-in-fact will
not be granted this
specific authority.
See A Guide to the
CalPERS Special Power of
Attorney (PUB 30) for a
detailed explanation of the
authority you are granting.
Section 3
General Statement of Authority Granted
I hereby grant to my attorney-in-fact full power and authority to transact matters on my behalf relating to
CalPERS, JRS I, JRS II, or LRS. I understand that I am granting authority to the attorney-in-fact regardless
of whether that person is related to me by blood, marriage, or legal domestic partnership. By signing this
Special Power of Attorney form I intend that:
•
My attorney-in-fact (
c
is;
c
is not) authorized to select any retirement payment option available
under the retirement plan other than the Unmodified Allowance.
Note: Allowing your attorney-in-fact to choose any retirement payment option available under
the retirement plan other than the Unmodified Allowance may reduce the monthly allowance
that would otherwise be paid to you during your lifetime.
•
My attorney-in-fact (
c
is;
c
is not) authorized to designate or change my beneficiary.
Note: Allowing your attorney-in-fact to designate or change your beneficiary will also allow
your attorney-in-fact to designate himself or herself as your beneficiary unless you specify
otherwise below.
On the following lines you may give special instructions limiting the powers granted to your
attorney(s)-in-fact.
Unless I indicate otherwise, this power of attorney shall be considered effective immediately and will
continue for the duration specified below or, if no duration is specified, until my death. My attorney-in-fact
is hereby instructed to notify CalPERS in writing of my disability, incapacity, or death immediately upon
its occurrence. I understand that I may revoke this power of attorney at any time by providing CalPERS
with a written statement of my intent to do so.
c
This durable power of attorney is to commence immediately and to remain in effect for my lifetime,
even if I become incapacitated, or until I specifically revoke it.
c
This limited power of attorney is to commence on _________________ and terminate on
______________________________.
c
This contingent/springing power of attorney is to commence only upon a determination that
I am incapacitated and/or unable to handle my own affairs. The determination of whether I am
incapacitated and/or unable to handle my own affairs for the purpose of this instrument shall
be made in a written statement signed by
______________________________________________________.
c
This general (non-durable) power of attorney is to terminate in its entirety if I become incapacitated.
The determination that I am incapacitated and/or unable to handle my own affairs for the purpose
of this instrument shall be made in a written statement signed by
______________________________________________________.
Section 4
Duration of Power of Attorney
Please be careful in
choosing when you
want your power of
attorney to commence
and/or terminate.
Check one box to
indicate your choice.
Checking multiple boxes
may invalidate this form.
The person that you
authorize to make
the determination of
incapacity must be at least
18 years old at the time
of designation. This person
may be, but is not required
to be, a licensed
physician or attorney.
Date (mm/dd/yyyy) or Event
Name and Relationship or Title of Person Authorized to Make the Determination
Name and Relationship or Title of Person Authorized to Make the Determination
Date (mm/dd/yyyy) or Event
Put your name and Social
Security number or CalPERS ID
at the top of every page
Name of Member Social Security Number or CalPERS ID
PERS-OSS-138 (12/18) Page 3 of 5
The authority granted by the CalPERS Special Power of Attorney form is limited to matters relating
to CalPERS, JRS I, JRS II, and LRS. The person designated as your attorney-in-fact does not have any
authority over your other real and/or personal property. If you wish that your attorney-in-fact have authority
over your real and/or personal property, it is recommended that you seek legal counsel.
You may notice that the language contained in the following Warning Statements refers to more
extensive authority than granted by the CalPERS Special Power of Attorney form. These Warning
Statements are required by Probate Code section 4128 and must be included in all preprinted
durable power of attorney forms even though the CalPERS Special Power of Attorney form does
not authorize your attorney-in-fact to do many of the things mentioned in the Warning Statements.
If you are concerned with the Warning Statements or the extent of the authority being granted by
the CalPERS Special Power of Attorney form, we again recommend that you seek legal counsel.
(Warning): Notice to Person Executing Durable Power of Attorney
A durable power of attorney is an important legal document. By signing a durable power of attorney,
you are authorizing another person to act for you, the principal. Before you sign this durable power
of attorney, you should know these important facts:
•
Your agent (attorney-in-fact) has no duty to act unless you and your agent agree otherwise
in writing.
•
This document gives your agent the powers to manage, dispose of, sell, and convey your real and
personal property, and to use your property as security if your agent borrows money on your behalf.
This document does not give your agent the power to accept or receive any of your property, in
trust or otherwise, as a gift, unless you specifically authorize the agent to accept or receive a gift.
•
Your agent will have the right to receive reasonable payment for services provided under this
durable power of attorney unless you state otherwise in this power of attorney.
•
The powers you give your agent will continue to exist for your entire lifetime, unless you state
that the durable power of attorney will last for a shorter period of time or unless you otherwise
terminate the durable power of attorney. The powers you give your agent in this durable power
of attorney will continue to exist even if you can no longer make your own decisions regarding
the management of your property.
•
You can amend or change this durable power of attorney only by executing a new durable power
of attorney or by executing an amendment through the same formalities as an original. You have
the right to revoke or terminate this power of attorney at any time as long as you are competent.
•
This durable power of attorney must be dated and must be acknowledged before a notary
public or signed by two witnesses. If it is signed by two witnesses, they must witness either
(1) the principal’s signing of the power of attorney or (2) the principal’s acknowledgement of his
or her signature. A durable power of attorney that may affect real property should be acknowledged
before a notary public so that it can easily be recorded.
•
You should read this durable power of attorney carefully. When effective, this durable power of
attorney will give your agent the right to deal with property that you now have or might acquire
in the future. This durable power of attorney is important to you. If you do not understand the
durable power of attorney or any provision of it, you should obtain the assistance of an attorney
or other qualified person.
Section 5
Warning Statements
Attorney(s)-in-fact may
not conduct business by
accessing your online
my|CalPERS account.
All contact with CalPERS
on your behalf must be
made by telephone, by
written correspondence,
or by visiting a
Regional Office.
The “agent” is the
attorney-in-fact.
Put your name and Social
Security number or CalPERS ID
at the top of every page
Name of Member Social Security Number or CalPERS ID
PERS-OSS-138 (12/18) Page 4 of 5
Section 6
Principal’s Acknowledgement and Execution
I am of sound mind and have consulted with an attorney or otherwise understand my elections. I am
executing this legal document under my own free will. I agree that any third party who receives a copy
of this document may act under it. Revocation of the power of attorney is not effective as to a third party
until the third party has actual knowledge of the revocation.
Date Executed (mm/dd/yyyy) City State
Signature of Principal County
Print Name of Principal (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
To be completed and
signed by the principal.
Signature of the agent
(attorney-in-fact)
is optional.
(Warning): Notice to Person Accepting the Appointment as Attorney-in-Fact
By acting or agreeing to act as the agent (attorney-in-fact) under this power of attorney you assume
the fiduciary and other legal responsibilities of an agent. These responsibilities include:
•
The legal duty to act solely in the interest of the principal and to avoid conflicts of interest.
•
The legal duty to keep the principal’s property separate and distinct from any other property
owned or controlled by you.
You may not transfer the principal’s property to yourself without full and adequate consideration or
accept a gift of the principal’s property unless this power of attorney specifically authorized you to
transfer property to yourself or accept a gift of the principal’s property. If you transfer the principal’s
property to yourself without specific authorization in the power of attorney, you may be prosecuted
for fraud and/or embezzlement. If the principal is 65 years of age or older at the time the property
is transferred to you without authority, you may also be prosecuted for elder abuse under Penal
Code section 368. In addition to criminal prosecution, you may also be sued in civil court.
I have read the foregoing notice and I understand the legal and fiduciary duties that I assume by
acting or agreeing to act as the agent (attorney-in-fact) under the terms of this power of attorney.
Lastly, the principal’s benefit shall not be subject to execution, process, or assignment under California
Public Employees’ Retirement Law section 21255.
Print Name of Agent (First Name, Middle Initial, Last Name)
Signature of Agent Date (mm/dd/yyyy)
Print Name of Agent (First Name, Middle Initial, Last Name)
Signature of Agent Date (mm/dd/yyyy)
Print Name of Agent (First Name, Middle Initial, Last Name)
Signature of Agent Date (mm/dd/yyyy)
Section 5, continued
Warning Statements, Continued
Put your name and Social
Security number or CalPERS ID
at the top of every page
Name of Member Social Security Number or CalPERS ID
Mail to:
CalPERS Benefit Services Division • P.O. Box 942716, Sacramento, California 94229-2716
PERS-OSS-138 (12/18) Page 5 of 5
Section 7
Witness Information
Must be completed by
a notary public if Section 7
is not completed.
CalPERS images these
documents. Please be
advised embossed seals
may not appear when this
document is reviewed. An
inked stamp is preferred.
Notary
State County
On _______________ before me ____________________________________, personally appeared
____________________________________, who proved to me on the basis of satisfactory evidence
to be the person(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 authorized capacity(ies), and that by his/her/
their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted,
executed the instrument. I certify under Penalty of Perjury under the laws of the State of California that
the foregoing paragraph is true and correct.
Witness my hand and official seal.
Signature of Notary Public Notary Seal
Print Name
Printed Name of Notary PublicDate (mm/dd/yyyy)
Name of Principal
I have witnessed the principal’s signature or the principal’s acknowledgment of his or her signature
designating power of attorney. I am of sound mind, I am an adult at least 18 years old, and I am not the
attorney-in-fact or successor attorney-in-fact. My signature certifies that the principal is known to me
and is the same person who signed and dated this Special Power of Attorney form.
Signature of Witness 1 Print Name of Witness 1 (First Name, Middle Initial, Last Name)
Address Date (mm/dd/yyyy)
City State ZIP
Signature of Witness 2 Print Name of Witness 2 (First Name, Middle Initial, Last Name)
Address Date (mm/dd/yyyy)
City State ZIP
Section 8
Notary Public Acknowledgement
Must be completed by
two individuals who are
at least 18 years of
age and are not named
as attorney-in-fact or
successor attorney-in-fact.
Alternately, Section 8
below must be completed
by a notary public.
A notary public or other officer completing this certificate verifies only the identity of the individual
who signed the document to which this certificate is attached, and not the truthfulness, accuracy,
or validity of that document.
Put your name and Social
Security number or CalPERS ID
at the top of every page
Name of Member Social Security Number or CalPERS ID
Privacy Notice
The privacy of personal information is of the utmost importance to CalPERS.
The following information is provided to you in compliance with the Information
Practices Act of 1977 and the Federal Privacy Act of 1974.
Information Purpose
The information requested is collected pursuant
to the Government Code (sections
20000 et seq.)
and will be used for administration of Board
duties under the Retirement Law, the Social
Security Act, and the Public Employees’ Medical
and Hospital Care Act, as the case may be.
Submission of the requested information is
mandatory. Failure to comply may result in
CalPERS being unable to perform its functions
regarding your status.
Please do not include information that is
not requested.
Social Security Numbers
Social Security numbers are collected on a
mandatory and voluntary basis. If this is CalPERS’
first request for disclosure of your Social Security
number, then disclosure is mandatory. If your
Social Security number has already been provided,
disclosure is voluntary. Due to the use of Social
Security numbers by other agencies for
identification purposes, we may be unable to
verify eligibility for benefits without the number.
Social Security numbers are used for the
following purposes:
1. Enrollee identification
2. Payroll deduction/state contributions
3. Billing of contracting agencies for employee/
employer contributions
4. Reports to CalPERS and other state agencies
5. Coordination of benefits among carriers
6. Resolving member appeals, complaints,
or grievances with health plan carriers
Information Disclosure
Portions of this information may be transferred
to other state agencies (such as your employer),
physicians, and insurance carriers, but only
in strict accordance with current statutes
regarding confidentiality.
Your Rights
You have the right to review your membership
files maintained by the System. For questions
about this notice, our Privacy Policy, or your rights,
please write to the CalPERS Privacy Ocer at
400 Q Street, Sacramento, CA 95811 or call us
at 888 CalPERS (or 888-225-7377).
May 2016
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Special Power of Attorney (California)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 March 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document