Statutory Durable Power Of Attorney Form Page 2
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3ON 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
PAGE 2
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