Power Of Attorney And Acknowledgment Form

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POWER OF ATTORNEY – LIMITED
(Note: Rules regarding legal sufficiency of a power of attorney vary by state. Please consult your
state rules and have the form reviewed by a lawyer in your state regarding additional language,
witness signatures, and notary requirements.)
1. I, __________________________ [INSERT NAME and ADDRESS] the undersigned hereby
make, constitute and appoint __________________________ [INSERT NAME and ADDRESS]
as my attorney-in-fact who shall have full power and authority to undertake and perform only the
following acts on my behalf:
[INSERT SPECIFIC MATTERS FOR WHICH POWER OF ATTORNEY IS BEING USED]
(i)
_______________________________________________________________
(ii)
_______________________________________________________________
(iii)
_______________________________________________________________
2. This Power of Attorney is effective immediately and will continue until I revoke it.
[OR]
_____________________________________________________________________
_____________________________________________________________________
2. This Power of Attorney shall be effective on the date of ______________ [INSERT DATE].
This Power of Attorney shall terminate on the date of ________________ [INSERT DATE],
unless I revoke it sooner. I may at any time or by any manner revoke this Power of Attorney.
3. This Power of Attorney __________________ [WILL OR WILL NOT] continue to be
effective even though I become incapacitated.
4. This Power of Attorney shall be governed by the State of _________________ [INSERT
STATE].
Signed this __________ day of ______________________, __________.
________________________________________
(Your signature)
________________________________________
(Your Social Security number)
State of ________________________, County of _________________________, USA
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