General Durable Power Of Attorney Form Page 2

CHECK ONE:

_________This Power of Attorney shall not be affected by any subsequent disability or

incapacity of the principal or by lapse of time. The rights, powers, and authority of the

attorney-in-fact shall begin and be in effect on ______________________, 20_____ (date

document is signed).

_________ This Power of Attorney becomes effective upon the disability or incapacity of

the principal.

This Power of Attorney may be revoked by the principal at any time that the principal has

the capacity to do so. Any revocation must be in writing and delivered to the named

attorney-in-fact.

Dated this _______ day of ________________________, 20____

_______________________________

Signature of Principal

_______________________________

Print or type name of Principal

Subscribed and sworn to before me this _____ day of ______________, 20_____ in

_______________(city), ______________________ (county), ______________________(state)

__________________________

Notary Public

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