Arkansas Statutory Form Power Of Attorney (Page 3 of 8) in pdf

[IF OPTION # 2 IS SELECTED, THEN THE FOLLOWING LANGUAGE NEEDS

TO BE IN PLACE:

For purposes of determining my incapacity, I shall be deemed to be

incapacitated in the event my agent shall come into possession of either of the following:

(1)

A valid court order appointing a guardian or conservator of my person or

estate, or otherwise holding me to be legally incapacitated to act on my own behalf; or

(2)

A duly executed and acknowledged written certificate of a licensed

physician certifying that such physician has examined me and has concluded that by reason

of accident, physical or mental illness, deterioration, or other similar cause, I have become

incapacitated and unable to act rationally and prudently in financial matters.

Such incapacity shall be deemed to continue until such court order or certificate have

become inapplicable or have been revoked. A physician’s certificate may be revoked by a

similar certificate to the effect that I am no longer incapacitated, executed either (i) by the

originally certifying physician or (ii) by another licensed physician.

I hereby authorize the physician(s) who examine me for the purposes of determining my

incapacity to disclose my physical or mental condition to the person(s) named herein as

my agent and attorney-in-fact. This authorization is intended to comply with the

requirements of the Health insurance Portability and Accountability Act of 1996 (HIPAA),

HIPAA regulations, and other State and Federal laws and regulations that may create a

right of privacy in the health information approved to be disclosed by this authorization.]

VI. NOMINATION OF GUARDIAN [THIS IS OPTIONAL & THE HEADING

SHOULD BE REMOVED IF CLIENT ELECTS NOT TO NOMINATE A

GUARDIAN]

[If it becomes necessary for a court to appoint a guardian of my estate or guardian of my person,

I nominate the following person for appointment [FULL NAME], who resides at [FULL

ADDRESS], and whose phone number is [PHONE NUMBER].

VII. RELIANCE ON THIS POWER OF ATTORNEY

Any person, including my agent, may rely upon the validity of this power of attorney or a copy

of it unless that person knows it has terminated or is invalid.

DATED this _______ day of __________________, 20___

Page 3 of 8

__________ Initials

Arkansas Statutory Form Power Of Attorney Page 3