Power Of Attorney - New York Statutory Short Form Page 9
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9New York State Bar Association
New York Statutory Short Form Power of Attorney, 8/18/10, Eff. 9/12/10
(f)
SIGNATURES OF WITNESSES:
By signing as a witness, I acknowledge that the principal signed the Statutory Gifts Rider in
my presence and the presence of the other witness, or that the principal acknowledged to me that
the principal's signature was affixed by him or her or at his or her direction. I also acknowledge
that the principal has stated that this Statutory Gifts Rider reflects his or her wishes and that he or
she has signed it voluntarily. I am not named herein as a permissible recipient of gifts.
____________________________
____________________________
Signature of witness 1
Signature of witness 2
_________________________
_____________________________________
Date
Date
_________________________
_____________________________________
Print Name
Print Name
_________________________
_____________________________________
Address
Address
_________________________
_____________________________________
City, State, Zip code
City, State, Zip code
(g)
This document prepared by:
2010 N.Y. Laws ch. 340
Page 9 of 9
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