N.y. Statutory Short Form Power Of Attorney Template (Page 4 of 7) in pdf

N.Y. Statutory Short Form Power of Attorney

Effective 09-01-09

(i) DESIGNATION OF MONITOR(S): (OPTIONAL)

I wish to designate ______________________________________________, whose address(es)

is (are) ______________________________________________________________________,

as monitor(s). Upon the request of the monitor(s), my agent(s) must provide the monitor(s) with

a copy of the power of attorney and a record of all transactions done or made on my behalf.

Third parties holding records of such transactions shall provide the records to the monitor(s)

upon request.

(j) COMPENSATION OF AGENT(S): (OPTIONAL)

Your agent is entitled to be reimbursed from your assets for reasonable expenses incurred on your

behalf. If you ALSO wish your agent(s) to be compensated from your assets for services rendered

on your behalf, initial the statement below. If you wish to define "reasonable compensation", you

may do so above, under "Modifications."

(

) My agent(s) shall be entitled to reasonable compensation for services rendered.

(k) ACCEPTANCE BY THIRD PARTIES: I agree to indemnify the third party for any claims

that may arise against the third party because of reliance on this Power of Attorney. I understand

that any termination of this Power of Attorney, whether the result of my revocation of the Power

of Attorney or otherwise, is not effective as to a third party until the third party has actual notice

or knowledge of the termination.

(l) TERMINATION: This Power of Attorney continues until I revoke it or it is terminated by

my death or other event described in section 5-1511 of the General Obligations Law. Section 5-

1511 of the General Obligations Law describes the manner in which you may revoke your Power

of Attorney, and the events which terminate the Power of Attorney.

(m) SIGNATURE AND ACKNOWLEDGMENT:

In Witness Whereof I have hereunto signed my name on _____________, 20____.

PRINCIPAL signs here: _______________________________________

State of _________________

County of _______________ ss.:

On the ____ day of _______________ in the year ______ before me, the undersigned, personally

appeared __________________________________, personally known to me or proved to me

on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to

the within instrument and acknowledged to me that he/she/they executed the same in

his/her/their capacity(ies), and that by his/her their signature(s) on the instrument, the

individual(s), or the person upon behalf of which the individual(s) acted, executed the

instrument.

________________________________________________

Signature and Office of individual taking acknowledgment

N.y. Statutory Short Form Power Of Attorney Template Page 4