Wisconsin Power Of Attorney Page 2
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2WITNESS SIGNATURES:
By signing as a witness, I am acknowledging the signature of the principal who signed in my presence and the presence of the
other witness, and the fact that he or she has stated that this power of attorney reflects his or her wishes and is being executed
voluntarily. I believe him or her to be of sound mind and capable of creating this power of attorney. I am not related to him or
her by blood, marriage or adoption, and, to the best of my knowledge, I am not entitled to any portion of his or her estate under
his or her will.
WITNESS
WITNESS
Dated:
_______________________________
Dated:
_________________________________
Signature:
_______________________________
Signature:
_________________________________
Print Name:
_______________________________
Print Name:
_________________________________
Address:
_______________________________
Address:
_________________________________
_______________________________
_________________________________
_______________________________
_________________________________
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NOTARIZATION
:
State of ___________________
)
)
County of __________________
)
)
Country of _________________
)
This document was acknowledged before me on this _____ day of ________________, 20____ by ______________________
___________________________.
___________________________________
Signature of Notarial Officer
___________________________________
(Seal, if any)
Title
My commission expires: ______________
ACCEPTANCE BY AGENT:
BY ACCEPTING OR ACTING UNDER THE APPOINTMENT, THE AGENT SIGNING BELOW ASSUMES THE FIDUCIARY
AND OTHER LEGAL RESPONSIBILITIES AND LIABILITIES OF AN AGENT.
____________________________________
_____________________________________
Printed Name of Agent
Signature
_____________________________
_____________________________________
Date
Relationship to Student
* * * * *
This document was drafted by the University of Wisconsin—Milwaukee Office of Legal Affairs.
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In order for a notarization taking place outside the United States to be valid, it must be performed under the jurisdiction of the
foreign nation by any of the following persons: (1) a notary public or notary; (2) a judge, clerk, or deputy clerk of a court of
record; or (3) any other person authorized by the law of that jurisdiction to perform notarial acts. The official stamp or seal of the
person performing the notarization should be affixed on this page.
Wisconsin Power of Attorney, Page 2/2
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