Power Of Attorney Form - Connecticut Page 3
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3Signature & Acknowledgment
Connecticut
This contract shall be governed by the laws of the State of
in __________ County and any
applicable Federal Law.
__________________________________________________________
Date____________
Signature
By accepting this appointment and acting under it, I the attorney-in-fact (“Agent”) do hereby assume the
legal responsibilities of an agent.
_____________________________________________________________________Date____________
Signature of Attorney-in-Fact
_____________________________________________________________________Date____________
ST
Signature of 1
Successor Agent
WITNESS #1) _________________________________
WITNESS #2) _________________________________
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