Statutory Durable Power Of Attorney Form (Page 2 of 3) in pdf

I grant my agent (attorney-in-fact) the power to apply my property to make gifts, except

that the amount of a gift to an individual may not exceed the amount of annual exclusions

allowed from the federal gift tax for the calendar year of the gift.

ON THE FOLLOWING LINES YOU MAY GIVE SPECIAL INSTRUCTIONS

LIMITING OR EXTENDING THE POWERS GRANTED TO YOUR AGENT.

________________________________________________________________

UNLESS YOU DIRECT OTHERWISE ABOVE, THIS POWER OF ATTORNEY IS

EFFECTIVE IMMEDIATELY AND WILL CONTINUE UNTIL IT IS REVOKED.

CHOOSE ONE OF THE FOLLOWING ALTERNATIVES BY CROSSING OUT THE

ALTERNATIVE NOT CHOSEN:

(A)

This power of attorney is not affected by my subsequent disability or incapacity.

(B)

This power of attorney becomes effective upon my disability or incapacity.

YOU SHOULD CHOOSE ALTERNATIVE (A) IF THIS POWER OF ATTORNEY IS

TO BECOME EFFECTIVE ON THE DATE IT IS EXECUTED.

IF NEITHER (A) NOR (B) IS CROSSED OUT, IT WILL BE ASSUMED THAT YOU

CHOSE ALTERNATIVE (A).

If Alternative (B) is chosen and a definition of my disability or incapacity is not

contained in this power of attorney, I shall be considered disabled or incapacitated for purposes

of this power of attorney if a physician certifies in writing at a date later than the date this power

of attorney is executed that, based on the physician's medical examination of me, I am mentally

incapable of managing my financial affairs. I authorize the physician who examines me for this

purpose to disclose my physical or mental condition to another person for purposes of this power

of attorney. A third party who accepts this power of attorney is fully protected from any action

taken under this power of attorney that is based on the determination made by a physician of my

disability or incapacity.

I agree that any third party who receives a copy of this document may act under it.

Revocation of the durable power of attorney is not effective as to a third party until the third

party receives actual notice of the revocation. I agree to indemnify the third party for any claims

that arise against the third party because of reliance on this power of attorney.

Statutory Durable Power Of Attorney Form Page 2