Statutory Form For Power Of Attorney (Page 3 of 3) in pdf

Statutory Form For Power Of Attorney Page 3

STRIKE THE PRECEDING SENTENCE IF YOU DO NOT WANT THIS POWER OF

ATTORNEY TO CONTINUE IF YOU BECOME DISABLED, INCAPACITATED, OR

INCOMPETENT.

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

of the power of attorney is not effective as to a third party until the third party learns 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.

Signed this ____ day of _______________, 20___.

____________________________________

(Your Signature)

____________________________________

(Your Social Security Number)

State of ________________________

(County) of _____________________

This document was acknowledged before me on

__________________________ (Date)

by: _________________________________

(Name of principal)

(Seal, if any)

____________________________________

(Signature of notarial officer)

____________________________________

(Title and Rank)

My commission expires: _______________

BY ACCEPTING OR ACTING UNDER THE APPOINTMENT, THE AGENT ASSUMES

THE FIDUCIARY AND OTHER LEGAL RESPONSIBILITIES OF AN AGENT.

B. A statutory power of attorney is legally sufficient under this act, if the wording of the form

complies substantially with subsection A of this section, the form is properly completed, and

the signature of the principal is acknowledged.

C. If the line in front of (N) of the form under subsection A of this section is initialed, an initial

on the line in front of any other power does not limit the powers granted by line (N).

STATUTORY FORM FOR POWER OF ATTORNEY

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Statutory Form For Power Of Attorney Page 3