Power Of Attorney Over Protected Person Or Minor Child Template Page 2

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Date
Typed or printed name
Address
City, State, Zip
Phone
E-mail
I certify that __________________________, who is known to me or who presented satisfactory
identification, has, while in my presence and while under oath or affirmation, voluntarily signed this
document and declared that it is true.
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Date:
Typed or printed name
Notary Seal
Power of Attorney over Protected person or
Approved Board of District Court Judges January 16, 2009
Page 2 of 2
Minor Child

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