Fillable Indiana Limited Financial Power Of Attorney Form (Page 3 of 6) in pdf

Indiana Limited Financial Power Of Attorney Form Page 3

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VIII. TERMS & CONDITIONS – Upon authorization by all parties, the Attorney-in-

Fact accepts their designation to act in the Principal’s best interests for all

financial decisions legal under law.

IX. THIRD PARTIES – I, the Principal, agree that any third party receiving a

copy via: physical copy, email, or fax that I, the Principal, will indemnify and

hold harmless any and all claims that may be put forth in reference to this

Limited Power of Attorney Form.

X. COMPENSATION – The Attorney-in-Fact agrees not to be compensated for

acting in the presence of the Principal. The Attorney-in-Fact may be, but not

entitled to, reimbursement for all: food, travel, and lodging expenses for

acting in the presence of the Principal.

XI. DISCLOSURE - I intend for my attorney-in-fact under this Power of Attorney

to be treated, as I would be with respect to my rights regarding the use and

disclosure of my individually identifiable health information or other medical

records. This release authority applies to any information governed by the

Health Insurance Portability and Accountability Act of 1996 (aka HIPAA), 42 USC

1320d and 45 CFR 160-164

XII. PRINCIPAL’S SIGNATURE - I, _________________________, the

Printed Name of Principal

Principal, sign my name to this power of attorney this ________ day of

Day

_________________________ and, being first duly sworn, do declare to the

Month

undersigned authority that I sign and execute this instrument as my power of

attorney and that I sign it willingly, or willingly direct another to sign for me,

that I execute it as my free and voluntary act for the purposes expressed in the

power of attorney and that I am eighteen years of age or older, of sound mind

and under no constraint or undue influence.

_________________________

Signature of Principal

Indiana Limited Financial Power Of Attorney Form Page 3

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