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I, __________________________, the principal, of ____________________________
[street address], State of ____________, hereby designate_______________________
[attorney-in-fact’s name], of ____________________________ [street address], State
of _______________, my attorney-in-fact (hereinafter my “attorney-in-fact”), to act as
set forth below, in my name, in my stead and for my benefit, hereby revoking any and all
powers of attorney I may have executed in the past.
I confer upon my attorney-in-fact the power to act on my behalf and in my stead, as if I
were present, and to exercise or perform the acts or powers I have designated with my
initials as set forth below.
My attorney-in-fact, shall NOT have the power to act on my behalf if I have not so
designated with my initials
___ 1. Power to Make Payments or Collect Monies Owed. My attorney-in-fact has
the power to make any payments on any accounts I may owe and to hold, collect
and request any sums that may be due, owing or payable to me or in which I may
hereinafter acquire an interest, in whatever form, whether liquidated or un-liquidated,
to have, use, and take all lawful means in my name for the collection and recovery
thereof, and to adjust, sell, compromise, and agree for the same and to execute and
deliver for me, on my behalf, and in my name, all endorsements, releases, receipts,
or other sufficient discharges for the same;
___ 2. Power to Acquire, Lease and Sell Personal Property. To acquire, purchase,
exchange, lease, grant options to sell, and sell and convey personal property, or any
interests therein, on such terms and conditions, including credit arrangements, as
my attorney-in-fact shall deem proper; to execute, acknowledge and deliver, under
seal or otherwise, any and all assignments, transfers, titles, papers, documents or
instruments which my attorney-in-fact shall deem necessary in connection therewith;
to purchase, sell or otherwise dispose of, assign, transfer and convey shares of
stock, bonds, securities and other personal property now or hereafter belonging to
me, whether standing in my name or otherwise, and wherever situated;
___ 3. Power to Acquire, Lease and Sell Real Property. To acquire, purchase,
exchange, lease, grant options to sell, and sell and convey real property, or any
interests therein, on such terms and conditions, including credit arrangements, as
my attorney-in-fact shall deem proper; to execute, acknowledge and deliver, under
seal or otherwise, any and all assignments, transfers, deeds, papers, documents or
instruments which my attorney-in-fact shall deem necessary in connection therewith;
___ 4. Management Powers. To maintain, repair, improve, invest, manage, insure, rent,
lease, encumber, and in any manner deal with any real or personal property, tangible
or intangible, or any interests therein, that I now own or may hereafter acquire, in my
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name and for my benefit, upon such terms and conditions as my attorney-in-fact
shall deem proper;
___ 5. Banking Powers. To open and close accounts, make, receive, and endorse
checks and drafts, deposit and withdraw funds, acquire and redeem certificates of
deposit, in banks, savings and loan associations, and other institutions, execute or
release such deeds of trust or other security agreements as may be necessary or
proper in the exercise of the rights and powers herein granted;
___ 6. Motor Vehicles. To apply for a Certificate of Title upon, and endorse and transfer
title thereto, for any automobile, truck, pickup truck, van, motorcycle, or other motor
vehicle, and to represent in such transfer or assignment that the title to said motor
vehicle is free and clear of all liens and encumbrances except those specifically set
forth in such transfer or assignment;
___ 7. Tax Powers. To act without limitation on my behalf with regard to federal income
taxes (Forms 1040, 1040EZ, 1040X, etc.), state and local income taxes, estate, gift
(Form 709) and other tax returns of all sorts, whether federal or state and local,
including where appropriate joint returns, FICA returns, payroll tax returns, claims for
refunds, requests for extensions of time to file returns or pay taxes, extensions and
waivers of applicable periods of limitation, protests and petitions to administrative
agencies or courts, including the tax court, regarding tax matters, and any and all
other tax related documents, including but not limited to consents and agreements
under Section 2032A of the Internal Revenue Code or any successor section thereto
and consents to split gifts and closing agreements, for all tax periods from 1980
through 2050, and for all jurisdictions; to complete Internal Revenue Service Form
2848, Power of Attorney and Declaration of Representative (or other prescribed
form) on my behalf as well as to perform all other functions contemplated by that
form whether they are required or merely permissible; to consent to any gift and to
utilize any gift-splitting provisions or other tax election; and to prepare, sign, and file
any claims for refund of any tax; to post bonds, receive confidential information and
contest deficiencies determined by the Internal Revenue Service or any state or
local taxing authority; to exercise any and all elections that I may have under federal,
state or local tax laws including without limitation the allocation of any generation-
skipping tax exemption to which I may be entitled; to the extent that I may have
omitted some power or discretion, some tax period, some form or some jurisdiction, I
hereby grant to my attorney-in-fact the power to amend the Internal Revenue
Service form power of attorney (presently Form 2848 or Form 2848-D) in my name;
___ 8. Safe-Deposit Boxes. To have access at any time or times to any safe-deposit
box rented by me or to which I may have access, where so ever located, including
drilling, if necessary, and to remove all or any part of the contents thereof, and to
surrender or relinquish said safe-deposit box; and any institution in which any such
safe-deposit box may be located shall not incur any liability to me or my estate as a
result of permitting my attorney-in-fact to exercise this power;
___ 9. Gift Making Powers. To make gifts, grants, or other transfers (including the
forgiveness of indebtedness and the completion of any charitable pledges I may
have made) without consideration, either outright or in trust to such person(s)
(including my attorney-in-fact hereunder) or organizations as my attorney-in-fact
shall select, including, without limitation, the following actions: (a) transfer by gift in
advancement of a bequest or devise to beneficiaries under my will or in the absence
of a will to my spouse and descendants in whatever degree; and (b) release of any
life interest, or waiver, renunciation, disclaimer, or declination of any gift to me by
will, deed, or trust;
___ 10. Lending and Borrowing. To make loans in my name; to borrow money in my
name, individually or jointly with others; to give promissory notes or other obligations
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therefor; and to deposit or mortgage as collateral or for security for the payment
thereof any or all of my securities, real estate, personal property, or other property of
whatever nature and wherever situated, held by me personally or in trust for my
___ 11. Contracts. To enter into contracts of whatever nature or kind in my name;
___ 12. Health Care. To take any and all steps necessary to arrange for my admission
to any type of health care facility, including, without limitation, a hospital,
rehabilitation facility, skilled nursing facility, or hospice, and to authorize the release
of my medical records in the discretion of my attorney-in-fact;
___ 13. HIPAA. To have the power and authority as my personal representative for all
purposes of the Health Insurance Portability and Accountability Act of 1996 (Pub. L.
No. 104-191);
___14. Power to Hire and Pay for Services. To retain such accountants, attorneys,
social workers, consultants, clerks, employees, workers, or other persons as my
agent shall deem appropriate in connection with the management of my property
and affairs and to make payments from my assets for the fees of such persons so
___ 15. Reimbursement of Attorney-in-Fact. To reimburse my attorney-in-fact for any
reasonable expenses incurred in connection with such services; and
___ 16. Power to Sue Third Parties Who Fail to Act Pursuant to Power of Attorney.
If any third party (including stock transfer agents, title insurance companies, banks,
credit unions, and savings and loan associations) with whom my attorney-in-fact
seeks to transact refuses to recognize my attorney-in-fact’s authority to act on my
behalf pursuant to this Power of Attorney, I authorize my attorney-in-fact to sue and
recover from such third party all resulting damages, costs, expenses, and attorney’s
fees incurred because of such failure to act. The costs, expenses, and attorney’s
fees incurred in bringing such action shall be charged against my general assets, to
the extent that they are not recovered from said third party.
___17. Other – Power to conduct the following ________________________________
This instrument is to be construed and interpreted as a general non-durable power of
attorney. The enumeration of specific powers herein is not intended to, nor does it, limit
or restrict the general powers herein granted to my attorney-in-fact. For a third party to
construe otherwise would be contrary to my intent. This instrument is executed and
delivered in the State of Washington and the laws of such state shall govern all
questions as to the validity of this power and the construction of its provisions.
Nevertheless, I intend that this instrument be given full force and effect in any state or
country in which I may find myself or in which I may own property, whether real or
personal. I direct that my attorney-in-fact not be required to give bond and, if any bond
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is required, that no sureties be required. I direct that photocopies of this instrument shall
have the same power and effect as the original.
To indicate when this document shall become effective, initial one of the following:
____ - Upon the date of this document with my authorization.
____ - The following date _____________________, 20_____.
To indicate when this document shall become terminated, initial all of the following that
apply (termination is effective at which of the following occurs first):
____ - On the following date _____________________, 20_____.
____ - When I have made a written revocation.
____ - When and if I become incapacitated and unable to make decisions as
determined by a physician.
Any party dealing with my attorney-in-fact hereunder may rely absolutely on the
authority granted herein and need not look to the application of any proceeds nor the
authority of my attorney-in-fact as to any action taken hereunder. In this regard, no
person who may in good faith act in reliance upon the representations of my attorney-in-
fact or the authority granted hereunder shall incur any liability to me or my estate as a
result of such act. I hereby ratify and confirm whatever my attorney-in-fact shall lawfully
do under this instrument. Any gift of property made by my attorney-in-fact in the proper
exercise of the gift-making powers specifically granted in section I (9) herein shall be a
full and complete delivery of title upon which third-party purchasers for value may rely.
My attorney-in-fact is authorized as he or she deems necessary to bring an action in
court so that this instrument shall be given the full power and effect that I intend on by
executing it.
IN WITNESS WHEREOF, I have on this ___ day of _______________, 20___,
executed this General Non-Durable Power of Attorney.
Principal’s Signature
Principal’s Printed Name
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I, ________________________, the attorney-in-fact named above, hereby
accept appointment as attorney-in-fact in accordance with the foregoing instrument.
Attorney-in-Fact’s Signature
Attorney-in-Fact’s Printed Name
We, the witnesses, each do hereby declare in the presence of the principal that the
principal signed and executed this instrument as his Power of Attorney in the presence
of each of us, that he signed it willingly, that each of us hereby signs this Power of
Attorney as witness at the request of the principal and in his presence, and that, to the
best of our knowledge, the principal is eighteen years of age or over, of sound mind,
and under no constraint or undue influence.
____________________ ____________________
Witness Address
____________________ ____________________
Witness Address
_____________ County, ss.
On this ____ day of _______________________, 20___, before me appeared
____________________, as Principal of this Power of Attorney who proved to me
through government issued photo identification to be the above-named person, in my
presence executed foregoing instrument and acknowledged that he executed the same
as his free act and deed.
Notary Public
My commission expires:_________
Pursuant to Chapter 11.94 RCW
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