Durable Power Of Attorney - New York Page 5
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106. Attorney-in-Fact, continued
Legal / Residential Address
Address
Provide the address used
for tax reporting. Cannot
be a PO Box, Mail Drop,
City
State/Province
Zip/Postal Code
Country
or c / o.
Mailing Address
Same as legal / residential address
Skip to ”U.S. Citizens.”
Address
City
State/Province
Zip/Postal Code
Country
Citizenship
U.S. Citizens
U.S. Citizen and tax resident.
If you checked this box, skip to
“Income Source,” below.
Foreign Citizens ONLY: Residency, Citizenship, and Government Identification
If you are NOT a U.S.
citizen, check one and
Permanent U.S. resident
Non-permanent U.S. resident
provide information.
Non-resident of U.S.
Country of Citizenship
Country of Tax Residency
City, State/Province, and Country of Birth
DHS Permanent
Employment Authorization
Passport with
Check one and attach
copy of Government
Resident Card
Document
U.S. visa
ID showing number
U.S. driver’s license
Foreign national identity
Passport without
and photo.
document
U.S. visa
ID Number
Country of Issuance, if not U.S.
State, if driver’s license
Income Source
Employed:
Self-employed:
Check one and
provide information.
Occupation
Employer Leave blank if self-employed.
Industry regulations
require us to ask for
Employer Address
this information.
City
State/Province
Zip/Postal Code
Country
Retired:
Not employed:
Source of Income Pension, investments, spouse etc.
Attorney-in-Fact continues on next page.
1.933269.101
027750105
Page 5 of 10
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