Pennsylvania General Durable Power Of Attorney Form (Page 6 of 7) in pdf

Pennsylvania General Durable Power Of Attorney Form Page 6

COUNTY OF ________________

On this, the _____ day of _________________, 20____, before me

________________________________________, the undersigned officer, personally appeared

_____________________________________________________________________________,

known to me (or satisfactorily proven) to be the person(s) whose name(s) is/are subscribed to the

within instrument, and acknowledged that __________________________________ executed

the same for the purposes therein contained.

In witness whereof, I hereunto set my hand and official seals.

[Notary Seal, if any]:

_______________________________

(Signature of Notarial Officer)

Notary Public for the Commonwealth of

Pennsylvania

My commission expires: ___________________

ACKNOWLEDGMENT EXECUTED BY AGENT

I, ________________________________________________ [name of agent], have read the attached

power of attorney and am the person identified as the agent for the principal. I hereby acknowledge that in

the absence of a specific provision to the contrary in the power of attorney or in 20 Pa.C.S. when I act as

agent:

I shall exercise the powers for the benefit of the principal.

I shall keep the assets of the principal separate from my assets.

I shall exercise reasonable caution and prudence.

I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal.

__________________________________

Agent's Signature

__________________________________

Agent's Printed Name

__________________________________

Date

PREPARATION STATEMENT

This document was prepared by the following individual:

Pennsylvania General Durable Power Of Attorney Form Page 6