Limited Power Of Attorney Authorization Form - Tennessee Treasury Department Page 2
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32. Agent Informa on
Name of Agent: ________________________________________________________________________________
Rela on to Designated Benefi ciary: ________________________________________________________________
(Investment Professional or Legal Representa ve)
Social Security Number or Tax Iden fi ca on Number: __________________________________________________
Name of Firm or En ty (if applicable): ______________________________________________________________
Mailing Address: _______________________________________________________________________________
City, State, and Zip Code: _________________________________________________________________________
Telephone Number: _____________________________
Alternate Telephone Number: ___________________
To the extent that I undertake to act under this power of a orney, I assume fi duciary and other legal responsibili es
of an Agent. I acknowledge that, as an Agent, I will neither have, nor acquire, any benefi cial interest in the Designated
Benefi ciary’s account during the Designated Benefi ciary’s life me, and I will administer the account for the benefi t of
the Designated Benefi ciary. I further acknowledge that I owe a duty of loyalty to and protec on of the best interests
of the Designated Benefi ciary, a duty to avoid confl icts of interest, a duty to use ordinary skill and prudence in the
exercise of these du es, and a duty to adequately inform the Designated Benefi ciary of ac ons taken in the exercise
of this power of a orney. I agree to direct any benefi ts derived from this Limited Power of A orney Authoriza on to
the Designated Benefi ciary.
Signature: _____________________________________
Date: _______________________________________
3. Authoriza on Descrip on
I, the Designated Benefi ciary listed in Sec on 1, appoint the Agent listed in Sec on 2 as my Agent. I authorize the
Agent to have the following authority or authori es:
Account Inquiry Access
Account Inquiry Access, Contribu ons, Investment Changes
Account Inquiry Access, Contribu ons, Investment Changes, Withdrawals
Full Authoriza on to Perform All Ac vi es, including Account Inquiry Access, Contribu ons, Investment Changes,
Withdrawals, Edit Designated Benefi ciary Informa on, Account Maintenance, Change Access Levels for other
Powers of A orney
Eff ec ve Date: _________________________________________________________________________________
RDA-11176
TR-0469
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