Power Of Attorney Form - Lasting

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Lasting Power of Attorney
Date ____/____/______
I
[Legal Name]
A resident of
[City][State]
Located at
[Address]
[City], [State] [Zip Code]
Appoint
[Legal Name]
A resident of
[City][State]
Located at
[Address]
[City], [State] [Zip Code]
As my attorney-in-fact to act on my behalf for the following lasting purpose of:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
This power of attorney shall take effect on ___/___/____, and will continue indefinitely or until
revoked by me.
I do hereby grant my attorney in fact complete authority to act in any reasonable manner that
is necessary to execute the above mentioned powers that are granted.
I agree that any third party who is given a copy of this power of attorney may act relying on it. I
also agree that revocation of this power of attorney is effective as to a third party only upon
receipt of actual notice by the third party. I agree to indemnify the third party for any loss that
may be suffered while carrying out this power of attorney.
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