The following statutory form of power of attorney is legally sufficient pursuant to the Uniform Power of Attorney act, available at http://www.law.upenn.edu/bll/archives/ulc/dpoaa.... 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 M... show moreEDICAL AND OTHER HEALTH-CARE DECISIONS FOR YOU. YOU MAY REVOKE THIS POWER OF ATTORNEY IF YOU LATER WISH TO DO SO.
STATUTORY POWER OF ATTORNEY
I Your name and address appoint 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
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 military service.
_______ (L) Retirement plan transactions.
_______ (M) Tax matters.
_______ (N) ALL OF THE POWERS LISTED ABOVE. YOU NEED NOTINITIAL ANY OTHER LINES IF YOU INITIAL LINE (N).
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 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 day of Month, Year
Your Social Security Number
State of State
(County) of County
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: Expiration Date
BY ACCEPTING OR ACTING UNDER THE APPOINTMENT, THE AGENT ASSUMES THE FIDUCIARY AND OTHER LEGAL RESPONSIBILITIES OF AN AGENT.