Fillable Iowa General Durable Power Of Attorney Form (Page 4 of 5) in pdf

Iowa General Durable Power Of Attorney Form Page 4

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OMI ATIO OF CO SERVATOR OR GUARDIA (OPTIO AL)

If it becomes necessary for a court to appoint a conservator or guardian of my estate or

guardian of my person, I nominate the following person(s) for appointment:

Name of Nominee for conservator or guardian of my estate:

Nominee’s Address:

Nominee’s Telephone Number:

Name of Nominee for guardian of my person:

Nominee’s Address:

Nominee’s Telephone Number:

RELIA CE O THIS POWER OF ATTOR EY

Any person, including my agent, may rely upon the validity of this power of attorney or a

copy of it unless that person knows it has terminated or is invalid.

SIG ATURE A D ACK OWLEDGME T

____________________________________________

_________________

Your Signature

Date

____________________________________________

Your Name Printed

____________________________________________

Your Address

____________________________________________

Your Telephone Number

STATEME T OF WIT ESS

On the date written above, the principal declared to me in my presence that this

instrument is his general durable power of attorney and that he or she had willingly

signed or directed another to sign for him or her, and that he or she executed it as his or

her free and voluntary act for the purposes therein expressed.

WITNESS No. 1

Signature:

Printed Name:

Iowa General Durable Power Of Attorney Form Page 4

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