Power Of Attorney Form

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Power of Attorney
Effective Date
____/____/______
I, do hereby
[Legal Name], AKA [Name]
A resident of
[City][State]
Located at
[Address]
[City], [State] [Zip Code]
Do Hereby Appoint
[Legal Name]
A resident of
[City][State]
Located at
[Address]
[City], [State] [Zip Code]
As my attorney-in-fact to act on my behalf for the following purpose(s):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
This power of attorney is to start to be effective on ____/____/______, and shall remain
effective until ____/____/______.
I do hereby grant my attorney-in-fact complete and full authority to act in any reasonable and
necessary manner for the purpose of exercising the above mentioned powers. I also, ratify all
the lawfully performed acts by my attorney-in-fact in exercising those powers.
I fully understand and agree that any third party who is given a copy of this Power of Attorney
may act relying on it. I also, agree that revocation of this Power of Attorney is effective as to a
third party only when they receive receipt of an actual notice by the third party. If due to
reliance on the Power of Attorney, a third party suffers any loss, I agree to pay for any third
party loss.
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