New York Statutory Short Form (Page 3 of 3) in pdf

New York Statutory Short Form Page 3

party having relied on the provisions of this instrument.

This Durable General Power of Attorney may be revoked by me at any time.

In Witness Whereof, I have hereunto signed my name this ........ day of .............., 200....

(YOU SIGN HERE:) º

_____________________________________

(

)

Signature of Principal

ACKNOWLEDGMENT

(for use within the State of New York )

STATE OF NEW YORK, COUNTY OF

ss.:

On the

day of

in the year

, before me, the undersigned, a Notary Public in and

for said State, personally appeared

personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose

name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the

same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or

the person upon behalf of which the individual(s) acted, executed the instrument.

______________________________________

Notary Public: State of New York

ACKNOWLEDGMENT

(for use outside the State of New York)

STATE OF

, COUNTY OF

ss.:

On the

day of

in the year

, before me, the undersigned, a Notary Public in and

for said State, personally appeared

personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose

name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the

same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or

the person upon behalf of which the individual(s) acted, executed the instrument, and that such individual made

such appearance before the undersigned in

(Insert city or political subdivision and state or county or other place acknowledgment taken).

____________________________________________

(Signature and office of individual taking acknowledgment)

1/1/2000

New York Statutory Short Form Page 3