State Of Louisiana Limited Power Of Attorney
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3LIMITED POWER OF ATTORNEY
UNITED STATES OF AMERICA
BY: _______________________________
STATE OF LOUISIANA
Name of Principal
TO: _______________________________
PARISH OF__________________________
Name of Agent
BE IT KNOWN, THAT ON THIS ___________ day of __________________, 20______
BEFORE ME, ______________________________, a Notary Public, duly commissioned
and qualified in and for the Parish of ______________________, State of Louisiana, and in the
presence of the witnesses hereinafter named and undersigned:
PERSONALLY CAME AND APPEARED ___________________________________, a
Name of Principal
person of the full age of majority, whose mailing address is _____________________________,
Street or P. O. Box of Principal
________________________________, State of Louisiana, and whose Social Security Number is
City and Zip of Principal
_________________________, hereinafter referred to as “Principal,” who declared that Principal
SSN of Principal
has made and appointed, and by these presents Principal does make, name, nominate, ordain,
authorize, constitute and appoint in Principal’s stead, __________________________________, a
Name of Agent
person of the full age of majority, whose mailing address is ______________________________,
Street of P.O. Box of Agent
________________________________, State of Louisiana, and whose Social Security Number is
City and Zip of Agent
__________________________, hereinafter referred to as “Agent,” to be Principal’s true and
SSN of Agent
lawful Agent and attorney-in-fact, giving, and by these presents granting unto the Agent, full
power and authority for Principal and in Principal’s name and behalf to wit:
To receive the retirement check payable in the name of Principal from the Louisiana State
Employees Retirement System (LASERS) and deposit said check into the Principal’s bank
account or negotiate said check to pay the bills, and handle the affairs of the Principal herein, and
the Principal does give, grant and convey unto his or her Agent, full and complete authority to do
as the Agent may in his or her sole and uncontrolled discretion deems necessary and proper, to
sign any and all documents, changes of address forms, receipts or instruments that the Agent may
deem necessary and proper in connection with the handling of the receipt of the Retirement Check
and payment of the Principal’s bills and finally, to do and perform every act in connection with the
proposed transaction substantially as hereinabove set forth, to the same extent and in the
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