Fillable Uniform Statutory Form Power of Attorney

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Uniform Statutory Form Power of Attorney

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Page 1 of 4
Uniform Statutory Form Power of Attorney
(California Probate Code Section 4401)
NOTICE: THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD AND
SWEEPING. THEY ARE EXPLAINED IN THE UNIFORM STATUTORY FORM POWER
OF ATTORNEY ACT (CALIFORNIA PROBATE CODE SECTIONS 4400–4465). THE
POWERS LISTED IN THIS DOCUMENT DO NOT INCLUDE ALL POWERS THAT ARE
AVAILABLE UNDER THE PROBATE CODE. ADDITIONAL POWERS AVAILABLE
UNDER THE PROBATE CODE MAY BE ADDED BY SPECIFICALLY LISTING THEM
UNDER THE SPECIAL INSTRUCTIONS SECTION OF THIS DOCUMENT. IF YOU
HAVE ANY QUESTIONS ABOUT THESE POWERS, OBTAIN COMPETENT LEGAL
ADVICE. THIS DOCUMENT DOES NOT AUTHORIZE ANYONE TO MAKE MEDICAL
AND OTHER HEALTHCARE DECISIONS FOR YOU. YOU MAY REVOKE THIS
POWER OF ATTORNEY IF YOU LATER WISH TO DO SO.
I, ________________________________________________ (your name and address)
appoint ________________________________________________ (name and
address of the person appointed, or of each person appointed if you want to designate
more than one) as my agent (attorney-in-fact) to act for me in any lawful way with
respect to the following initialed subjects:
TO GRANT ALL OF THE FOLLOWING POWERS, INITIAL THE LINE IN FRONT OF
(N) AND IGNORE THE LINES IN FRONT OF THE OTHER POWERS.
TO GRANT ONE OR MORE, BUT FEWER THAN ALL, OF THE FOLLOWING
POWERS, INITIAL THE LINE IN FRONT OF EACH POWER YOU ARE GRANTING.
TO WITHHOLD A POWER, DO NOT INITIAL THE LINE IN FRONT OF IT. YOU MAY,
BUT NEED NOT, CROSS OUT EACH POWER WITHHELD.
__________ (A) Real property transactions.
__________ (B) Tangible personal property transactions.
__________ (C) Stock and bond transactions.
__________ (D) Commodity and option transactions.
__________ (E) Banking and other financial institution transactions.
__________ (F) Business operating transactions.
__________ (G) Insurance and annuity transactions.
__________ (H) Estate, trust, and other beneficiary transactions.
__________ (I) Claims and litigation.
__________ (J) Personal and family maintenance.
__________ (K) Benefits from social security, medicare, medicaid, or other
governmental programs, or civil or military service.
__________ (L) Retirement plan transactions.
__________ (M) Tax matters.
__________ (N) ALL OF THE POWERS LISTED ABOVE.
YOU NEED NOT INITIAL ANY OTHER LINES IF YOU INITIAL LINE (N).
Page 2 of 4
SPECIAL INSTRUCTIONS:
ON THE FOLLOWING LINES YOU MAY GIVE SPECIAL INSTRUCTIONS LIMITING
OR EXTENDING THE POWERS GRANTED TO YOUR AGENT.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
UNLESS YOU DIRECT OTHERWISE ABOVE, THIS POWER OF ATTORNEY IS
EFFECTIVE IMMEDIATELY AND WILL CONTINUE UNTIL IT IS REVOKED.
This power of attorney will continue to be effective even though I become incapacitated.
STRIKE THE PRECEDING SENTENCE IF YOU DO NOT WANT THIS POWER OF
ATTORNEY TO CONTINUE IF YOU BECOME INCAPACITATED.
EXERCISE OF POWER OF ATTORNEY WHERE
MORE THAN ONE AGENT DESIGNATED
If I have designated more than one agent, the agents are to act
________________________________.
IF YOU APPOINTED MORE THAN ONE AGENT AND YOU WANT EACH AGENT TO
BE ABLE TO ACT ALONE WITHOUT THE OTHER AGENT JOINING, WRITE THE
WORD “SEPARATELY” IN THE BLANK SPACE ABOVE. IF YOU DO NOT INSERT
ANY WORD IN THE BLANK SPACE, OR IF YOU INSERT THE WORD “JOINTLY,”
THEN ALL OF YOUR AGENTS MUST ACT OR SIGN TOGETHER.
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. I agree to indemnify the third party for any
claims that arise against the third party because of reliance on this power of attorney.
Signed this ____ day of _________________________, 20____.
________________________________________
(your signature)
State of ________________________, County of _________________________,
BY ACCEPTING OR ACTING UNDER THE APPOINTMENT, THE AGENT ASSUMES
THE FIDUCIARY AND OTHER LEGAL RESPONSIBILITIES OF AN AGENT.
Page 3 of 4
CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC
State of California
County of ________________________
On ________________________, 20____, 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 __________________________________ (Seal, if any)
Notice to Person Executing Durable Power of Attorney
A durable power of attorney is an important legal document. By signing the 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 provide 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 respecting the management of your property.
Page 4 of 4
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 durable power of attorney
at any time, so 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 signing of the power of attorney or (2) the principal’s signing or
acknowledgment 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 may 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. The durable power of attorney is important to you. If you
do not understand the durable power of attorney, or any provision of it, then you should
obtain the assistance of an attorney or other qualified person.
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:
1. The legal duty to act solely in the interest of the principal and to avoid conflicts of
interest.
2. 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 authorizes 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 that 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.
Signature of Agent: __________________________________ Date: ______________
Print Name of Agent: __________________________________
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Uniform Statutory Form Power of Attorney

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Completed 25 July 2021

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