Statutory Power Of Attorney Page 5
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13SPECIAL INSTRUCTIONS:
You may give special instructions on the following lines:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
EFFECTIVE DATE
This power of attorney is effective immediately unless I have stated otherwise in
the Special Instructions.
NOMINATION OF CONSERVATOR OR GUARDIAN (OPTIONAL)
If it becomes necessary for a court to appoint a conservator or guardian of my
person, I nominate the following person(s) for appointment:
Name of Nominee for conservator of my estate:
______________________________________________________________________
Nominee’s address: _____________________________________________________
Nominee’s telephone number: _____________________________________________
Name of Nominee for guardian of my person: _________________________________
Nominee’s address: _____________________________________________________
Nominee’s telephone number: _____________________________________________
RELIANCE ON THIS POWER OF ATTORNEY
Any person, including my agent, my relay upon the validity of this power of
attorney or a copy of it unless that person knows it has terminated or is invalid.
SIGNATURE AND ACKNOWLEDGMENT
Your signature: _______________________________________
Date: _____________________________
Your name printed: _____________________________________
Your address: _________________________________________
Your telephone number: _________________________________
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