Power Of Attorney - Authorization For Certain Gift Transactions (Page 4 of 4) in pdf

Power Of Attorney - Authorization For Certain Gift Transactions Page 4

Power of Attorney, NY Statutory Gifts Rider

Effective 09/12/2010

(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.

WITNESS 1:

WITNESS 2:

___________________________________

(Signature of Witness 1)

(Signature of Witness 2)

___________________________________

(Date)

___________________________________

(Printed Name)

___________________________________

(Address)

___________________________________

(City, State, Zip Code)

(g) This document prepared by: ____________________________________________

______.

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Power Of Attorney - Authorization For Certain Gift Transactions Page 4