Form Pa-1 - Special Power Of Attorney - Individual - 2007 Page 2
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1
2
3
4COLUMN A
COLUMN B
Lines 15 - 18 refer to person listed on Line 1.
Lines 19 - 22 refer to person listed on Line 3.
AFFIRMATION OF WITNESS
AFFIRMATION OF WITNESS
for person on Line 1
for person on Line 3
I affirm that the principal appeared to be of sound mind
I affirm that the principal appeared to be of sound mind
and free from duress at the time this power of attorney
and free from duress at the time this power of attorney
was signed, and that he/she affirmed that he/she was
was signed, and that he/she affirmed that he/she was
aware of the nature of this document and signed it freely
aware of the nature of this document and signed it freely
and voluntarily.
and voluntarily.
Print name of Witness
Print name of Witness
15
19
16
Signature of Witness for person on Line 1
Date
20
Signature of Witness for person on Line 3
Date
17
21
FOR USE BY NOTARY
FOR USE BY NOTARY
for person on Line 1
for person on Line 3
State of ______________________________
State of ______________________________
County of ____________________________ , SS.
County of ____________________________ , SS.
At ______________________________________ on the
At ______________________________________ on the
City
City
______ day of ____________ , 20 ______ personally
______ day of ____________ , 20 ______ personally
Year
Day
Month
Year
Day
Month
appeared the principal who acknowledged this Instrument
appeared the principal who acknowledged this Instrument
signed by him/her to be his/her free act and deed,
signed by him/her to be his/her free act and deed,
Before me _________________________________
Before me _________________________________
My Commission Expires: _____________________
My Commission Expires: _____________________
ATTESTATION OF AGENT
ATTESTATION OF AGENT
for person on Line 1
for person on Line 3
I hereby attest that I accept appointment as agent for
I hereby attest that I accept appointment as agent for
the principal and:
the principal and:
that I understand my duties under this power of
that I understand my duties under this power of
attorney and under the law;
attorney and under the law;
that I understand that I have a duty to act for the
that I understand that I have a duty to act for the
principal as to specified transactions or types of
principal as to specified transactions or types of
transactions if expressly required to do so in this
transactions if expressly required to do so in this
power of attorney;
power of attorney;
that I hereby specifically acknowledge and accept such
that I hereby specifically acknowledge and accept such
duties to act in signing this power of attorney;
duties to act in signing this power of attorney;
in the case of such a duty to act, my agreement to act
in the case of such a duty to act, my agreement to act
on behalf of the principal is enforceable against me
on behalf of the principal is enforceable against me
regardless of whether there is any consideration to
regardless of whether there is any consideration to
support a contractual obligation;
support a contractual obligation;
that I understand and acknowledge in signing this
that I understand and acknowledge in signing this
power of attorney, that if I have been selected as
power of attorney, that if I have been selected as
agent with the expectation that I have special skills
agent with the expectation that I have special skills
or expertise I will use those skills on behalf of the
or expertise I will use those skills on behalf of the
principal.
principal.
18
Signature of Agent (person on Line 5)
Date
22
Signature of Agent (person on Line 5)
Date
Form PA-1(Indiv.)
rev. 1/07
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