Special Power Of Attorney For Closing On Real Estate Page 2
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________________________________
Principal
Address of Principal: ____________________________________________
Phone number where Principal can be contacted: _______________
E-mail address of Principal: _______________________
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(THIS POWER OF ATTORNEY WILL NOT BE EFFECTIVE UNLESS IT IS NOTARIZED AND
SIGNED BY AT LEAST ONE ADDITIONAL WITNESS, USING THE FORM BELOW.)
The undersigned witness certifies that ........................................................................., known to
me to be the same person whose name is subscribed as principal to the foregoing power of
attorney, appeared before me and the notary public and acknowledged signing and delivering
the instrument as the free and voluntary act of the principal, for the uses and purposes therein
set forth. I believe him or her to be of sound mind and memory. The undersigned witness also
certifies that the witness is not: (a) the attending physician or mental health service provider or a
relative of the physician or provider; (b) an owner, operator, or relative of an owner or operator of
a health care facility in which the principal is a patient or resident; (c) a parent, sibling,
descendant, or any spouse of such parent, sibling, or descendant of either the principal or any
agent or successor agent under the foregoing power of attorney, whether such relationship is by
blood, marriage, or adoption; or (d) an agent or successor agent under the foregoing power of
attorney.
Dated: ................................
.........................................................................
Witness
The undersigned, a notary public in and for the above county and state, certifies that
.........................................., known to me to be the same person whose name is subscribed as
principal to the foregoing power of attorney, appeared before me and the witness(es)
.................................................. (and .....................................................) in person and
acknowledged signing and delivering the instrument as the free and voluntary act of the
principal, for the uses and purposes therein set forth (, and certified to the correctness of the
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