Power Of Attorney Form For Care Of Minor Nj Page 4

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  W itnesses:   N ame   a nd   A ddress  
 
__________________________  
 
__________________________  
 
__________________________  
 
 
STATE   O F   _ ___________________  
 
COUNTY   O F   _ ____________________  
 
PERSONALLY   c ame   a nd   a ppeared   b efore   m e,   t he   u ndersigned   a uthority   i n   a nd   f or  
the   j urisdiction   a foresaid,   t he   w ithin   n amed   _ ________________,   w ho   a cknowledged   t o  
me   t hat   s he/he/they   s igned,   e xecuted   a nd   d elivered   t he   f oregoing   P ower   o f  
Attorney   o n   t he   d ay   a nd   y ear   t herein   m entioned.  
 
GIVEN   u nder   m y   h and   a nd   o fficial   s eal   o f   o ffice,   t his   t he   _ ___   d ay   o f  
 
________________,   2 0___   .  
 
____________________________  
 
NOTARY   P UBLIC  
 
My   C ommission   E xpires:  
 
_____________________  
   
 
Acceptance   b y   A ttorney-­‐in-­‐Fact  
 
I,_____________________________   ,   h ereby   a ccept   t he   d uties,   p owers   a nd   r esponsibilities  
contained   i n   t he   a bove   a nd   f oregoing   P ower   o f   A ttorney.  
 
DATED   t his   t he   _ _____   d ay   o f   _ ___________,   2 0___   .  
 
_______________________________  
 
Signature  
 
   
 

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