STATUTORY FORM FOR POWER OF ATTORNEY A. The following statutory form of power of attorney is legally sufficient: STATUTORY POWER OF ATTORNEY NOTICE: THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD AND SWEEPING. THEY ARE EXPLAINED IN THE UNIFORM STATUTORY FORM POWER OF ATTORNEY ACT. IF YOU HAVE ANY QUESTIONS ABOUT THESE POWERS, OBTAIN COMPETENT LEGAL ADVICE. THIS DOCUMENT DOES NOT AUTHORIZE ANYONE TO MAKE MEDICAL AND OTHER HEALTH-CARE DECISIONS FOR YOU. YOU MAY REVOKE THIS POWER OF ATTORNEY IF YOU LATER WISH TO DO SO. I __________________________ (insert your name and address) appoint ____________________________ (insert the name and address of the person appointed) 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. INITIAL _______ (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 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). SPECIAL INSTRUCTIONS: ON THE FOLLOWING LINES YOU MAY GIVE SPECIAL INSTRUCTIONS LIMITING OR EXTENDING THE POWERS GRANTED TO YOUR AGENT. ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ (Attach additional pages if needed.) 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 disabled, incapacitated, or incompetent. STRIKE THE PRECEDING SENTENCE IF YOU DO NOT WANT THIS POWER OF ATTORNEY TO CONTINUE IF YOU BECOME DISABLED, INCAPACITATED, OR INCOMPETENT. 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 learns 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 _______________, 19__ ______________________________ (Your Signature) _______________________________ (Your Social Security Number) State of ______________________ (County) of ___________________ This document was acknowledged before me on _______________ (Date) by _________________________ (Name of principal) _______________________________ (Signature of notarial officer) (Seal, if any) _______________________________ (Title and Rank) My commission expires:________________ BY ACCEPTING OR ACTING UNDER THE APPOINTMENT, THE AGENT ASSUMES THE FIDUCIARY AND OTHER LEGAL RESPONSIBILITIES OF AN AGENT. B. A statutory power of attorney is legally sufficient under this act, if the wording of the form complies substantially with subsection A of this section, the form is properly completed, and the signature of the principal is acknowledged. C. If the line in front of (N) of the form under subsection A of this section is initialed, an initial on the line in front of any other power does not limit the powers granted by line (N).
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