North Carolina Statutory Short Form Of General Power Of Attorney Page 2

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(If power of attorney is to be effective to terminate or direct the administration of a
custodial trust created under the Uniform Custodial Trust Act, add: 'In the event of my
subsequent incapacity or mental incompetence, the attorney-in-fact of this power of
attorney shall have the power to terminate or to direct the administration of any custodial
trust of which I am the beneficiary.')
(If power of attorney is to be effective to determine whether a beneficiary under the
Uniform Custodial Trust Act is incapacitated or ceases to be incapacitated, add: 'The
attorney-in-fact of this power of attorney shall have the power to determine whether I am
incapacitated or whether my incapacity has ceased for the purposes of any custodial trust
of which I am the beneficiary.')
Dated___________, _______.
(Seal)
Signature __________________
STATE OF ____________________ COUNTY OF _______________
On this ______ day of___________, ______, personally appeared before me, the said
named ______________________________ to me known and known to me to be the
person described in and who executed the foregoing instrument and he (or she)
acknowledged that he (or she) executed the same and being duly sworn by me, made oath
that the statements in the foregoing instrument are true.
My Commission Expires ______________________.
__________________________ (Signature of Notary Public)
Notary Public (Official Seal)

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