Form Statutory Power Of Attorney - State Of Colorado (Page 3 of 4) in pdf

5. LIMITATION ON AGENT'S AUTHORITY

An agent that is not my ancestor, spouse, or descendant MAY NOT use my property to benefit the agent or a

person to whom the agent owes an obligation of support unless I have included that authority in the special

instructions.

6. SPECIAL INSTRUCTIONS (OPTIONAL)

You may give special instructions on the following line: ______________________________________________

__________________________________________________________________________________________

7. EFFECTIVE DATE

This power of attorney is effective immediately unless I have stated otherwise in the special instructions.

8. NOMINATION OF CONSERVATOR OR GUARDIAN (OPTIONAL)

If it becomes necessary for a court to appoint a conservator of my estate or guardian of my person, I nominate the

following person(s) for appointment:

Name of nominee for conservator of my estate: ______________________________

Nominee's address: ____________________________________________________________

Nominee's telephone number: ______________________________

Name of nominee for guardian of my person: ______________________________

Nominee's address: ____________________________________________________________

Nominee's telephone number: ______________________________

9. RELIANCE ON THIS POWER OF ATTORNEY

Any person, including my agent, may rely upon the validity of this power of attorney or a copy of it unless that

person knows it has terminated or is invalid.

10. SIGNATURE AND ACKNOWLEDGMENT

______________________________

____________________

Your signature

Date

______________________________

Your name printed

Your telephone number

Your address ____________________________________________________________

WITNESS AFFIDAVIT (OPTIONAL)

I/we declare that, being first duly sworn, that the principal signed and executed this instrument, knowingly and

willingly, as the principal’s Power of Attorney, and I/we signed this instrument as witness, in the conscious

presence of the principal, and at the time of the execution of this instrument, the principal, according to my/our

best knowledge and belief, was aware and of sound mind, and under no constraint or undue influence.

______________________________

____________________

Witness #1 signature

Date

______________________________

Witness #1 name printed

Witness #1 telephone number

______________________________

____________________

Witness #2 signature

Date

______________________________

Witness #2 name printed

Witness #2 telephone number

==================================================================================

State of Colorado,

County of ____________________

Acknowledged before me by ______________________________ (principal), and subscribed and sworn to, or

affirmed, before me by ______________________________ (witness) and ______________________________

(witness) on ____________________ (date).

Signature of notary ______________________________ (Seal)

My commission expires: ____________________

Form Statutory Power Of Attorney - State Of Colorado Page 3

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