Power Of Attorney New York Statutory Short Form/power Of Attorney New York Statutory Major Gifts Rider Authorization To Make Major Gifts Or Other Transfers Form (Page 9 of 9) in pdf

Power Of Attorney New York Statutory Short Form/power Of Attorney New York Statutory Major Gifts Rider Authorization To Make Major Gifts Or Other Transfers Form Page 9

By signing as a witness, I acknowledge that the principal signed the Major Gifts Rider in my

presence and the presence of the other witness, or that the principal acknowledged to me that

the principal's signature was affixed by him or her or at his or her direction. I also acknowledge

that the principal has stated that this Major Gifts Rider reflects his or her wishes and that he or

she has signed it voluntarily. I am not named herein as a permissible recipient of major gifts.

Signature of witness 1

Signature of witness 2

______________________________

____________________________________

Date

______________________________

____________________________________

Print Name

______________________________

____________________________________

Address

_____________________________

____________________________________

City, State, Zip code

(g) This document prepared by: ____________________________________________________

2008 N.Y. Laws ch. 644, § 19, 5-1514; 2009 N.Y. Laws ch. 4 (amending effective date from March 1, 2009 to

September 1, 2009).

Power Of Attorney New York Statutory Short Form/power Of Attorney New York Statutory Major Gifts Rider Authorization To Make Major Gifts Or Other Transfers Form Page 9

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