New York Statutory Short Form Poa Page 7

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(o) AGENT'S SIGNATURE AND ACKNOWLEDGMENT OF APPOINTMENT:
It is not required that the principal and the agent(s) sign at the same time, nor that multiple agents sign at
the same time.
I/we, _____________________________________________________________________________,
have read the foregoing Power of Attorney. I am/we are the person(s) identified therein as agent(s) for
the principal named therein.
I/we acknowledge my/our legal responsibilities.
(AGENT SIGNS HERE:) ►__________________________________________
(Signature of Agent)
STATE OF NEW YORK
:
: ss.:
COUNTY OF __________
:
On the __________ day of __________ in the year __________ before me, the undersigned, personally
appeared __________________________________________, personally known to me or proved to me
on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the
within instrument and acknowledged to me that he/she/they executed the same in his/her/their
capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person
upon behalf of which the individual(s) acted, executed the instrument.
_____________________________
Notary Public
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