Special Power Of Attorney Page 5
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1
2
3
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5Put your name and
Social Security number
–
–
at the top of every page.
Name of Principal
Social Security Number
Witness Information
Section 8
I have witnessed the principal’s signature or the principal’s acknowledgment of the signature designating
To be completed by
two witnesses who
power of attorney. I attest to the principal’s knowledge that I am of sound mind. I am an adult at least 18
are not named as
years old and not the attorney-in-fact. My signature certifi es that the principal is known to me, is the same
attorneys-in-fact.
person who signed and dated this affi davit, and that I am of sound mind.
Signature of Witness 1
Name of Witness 1 (printed)
Address
Date
City
State
ZIP
Signature of Witness 2
Name of Witness 2 (printed)
Address
Date
City
State
ZIP
Notary Public Acknowledgement
Section 9
Notary
To be completed by
a Notary Public.
State
County
This section does
On _______________ before me ____________________________________, personally appeared
not need to be
Date (mm/dd/yyyy)
Printed Name of Notary Public
completed if you have
____________________________________, who proved to me on the basis of satisfactory evidence
completed Section 8.
Name of Principal
CalPERS images these
to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to
documents. Please
me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/
be advised embossed
their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted,
seals may not appear
executed the instrument. I certify under Penalty of Perjury under the laws of the State of California that the
when this document
Foregoing paragraph is true and correct.
is reviewed. An inked
stamp is preferred.
Witness my hand and offi cial seal.
Signature of Notary Public
Notary Seal
Print Name
Mail to:
CalPERS Benefi t Services Division • P.O. Box 942716, Sacramento, California 94229-2716
PERS-OSS-138 (8/09)
Page 5 of 5
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