Washington Durable Power Of Attorney Will To Live Form Page 4

This power of attorney shall become effective in the event I become disabled or incompetent.

This power of attorney may be revoked in writing by my giving written notice to the attorney-in-

fact, or if applicable, to the successor attorney-in-fact.

DATED _______________________________________, ___________.

____________________________________

(your signature)

STATE OF WASHINGTON

)

) ss

COUNTY OF ______________________

)

I certify that I know or have satisfactory evidence that (name)____________________________

signed this instrument and acknowledged it to be his or her free and voluntary act for the use

and purposes mentioned in the instrument.

_______________________________

____________________________________

(Date)

(Notary Public)

My Appointment Expires:

____________________________________

Form Prepared 2001

Clerical Changes Made 2005

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