Basic Statutory Durable Power Of Attorney Template (Page 3 of 6) in pdf

Basic Statutory Durable Power Of Attorney Template Page 3

YOU SHOULD CHOOSE ALTERNATIVE (A) IF THIS POWER OF ATTORNEY IS TO

BECOME EFFECTIVE ON THE DATE IT IS EXECUTED.

IF NEITHER (A) NOR (B) IS CROSSED OUT, IT WILL BE ASSUMED THAT YOU CHOSE

ALTERNATIVE (A).

If Alternative (B) is chosen and a definition of my disability or incapacity is not contained in this

power of attorney, I shall be considered disabled or incapacitated for purposes of this power of

attorney if a physician certifies in writing at a date later than the date this power of attorney is

executed that, based on the physician's medical examination of me, I am mentally incapable of

managing my financial affairs. I authorize the physician who examines me for this purpose to

disclose my physical or mental condition to another person for purposes of this power of

attorney. A third party who accepts this power of attorney is fully protected from any action

taken under this power of attorney that is based on the determination made by a physician of my

disability or incapacity.

I agree that any third party who receives a copy of this document may act under it. Revocation

of the durable power of attorney is not effective as to a third party until the third party receives

actual notice of the revocation. I agree to indemnify the third party for any claims that arise

against the third party because of reliance on this power of attorney.

If any agent named by me dies, becomes legally disabled, resigns, or refuses to act, I name the

following (each to act alone and successively, in the order named) as successor(s) to that agent:

_________________________________________________________________________.

Signed this ______ day of __________, _____________

___________________________

(your signature)

State of _______________________

County of ______________________

This document was acknowledged before me on ____________(date) by __________________

(name of principal).

______________________________

(signature of notarial officer)

(Seal, if any, of notary) ________________________________________

(printed name) ________________________________________

My commission expires: ______________

Statutory Durable Power of Attorney

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Basic Statutory Durable Power Of Attorney Template Page 3