Limited Power of Attorney 
BE IT ACKNOWLEDGED that I, ________________________________  Full Name 
_____________________________, the “Principal”, do hereby grant a limited 
 social security number 
and specific power of attorney to ____________________________________ of  Full Name 
________________________________________________________________________  Address Phone 
as my “Attorney-in-Fact”. 
Said Attorney-in-Fact shall have full power and authority to undertake and perform only the following acts on my behalf: 
1. _______________________________________________________________ 2. _______________________________________________________________ 
3. _______________________________________________________________ 
The authority herein shall include such incidental acts as are reasonably required to carry out and perform the specific authorities granted herein. My Attorney-in-Fact  agrees to accept this appointment subject to its terms, and agrees to act and  perform in said fiduciary capacity consistent with my best interest, as my Attorney in-Fact in its discretion deems advisable. This power of attorney is effective upon  execution.  
This power of attorney may be revoked by any of the following: 
(Initial and Check the Box if Applicable) 
______ ☐ - By the Principal at anytime by authorizing a Revocation. 
______ ☐ - When the above stated one (1) time power or responsibility has been  completed. 
______ ☐ - On the ____ day of _______________________, 20___. 
This power of attorney form shall automatically be revoked upon my death or  incapacitation, provided any person relying on this power of attorney shall have full  rights to accept and reply upon the authority of my Attorney-in-Fact until in receipt  of actual notice of revocation.
Page 1 of 3 
State Law. This Power of Attorney is governed by the laws of the State of  _______________________. 
Signed this ____ day of _______________________, 20___. 
___________________________ 
Signature 
___________________________ 
Print Name 
ACCEPTANCE OF APPOINTMENT 
I, ________________________, the attorney-in-fact named above, hereby accept  appointment as attorney-in-fact in accordance with the foregoing instrument. 
__________________________ 
Attorney-in-Fact’s Signature 
__________________________ 
Attorney-in-Fact’s Printed Name 
WITNESSES 
We, the witnesses, each do hereby declare in the presence of the principal that the  principal signed and executed this instrument as his Power of Attorney in the presence of  each of us, that he signed it willingly, that each of us hereby signs this Power of Attorney  as witness at the request of the principal and in his presence, and that, to the best of our  knowledge, the principal is eighteen years of age or over, of sound mind, and under no  constraint or undue influence. 
____________________ _____________________________________ Witness Signature Address 
____________________ _____________________________________ Witness Print Name City, State & Zip Code 
____________________ _____________________________________ Witness Signature Address 
____________________ _____________________________________ Witness Print Name City, State & Zip Code
Page 2 of 3 
ACKNOWLEDGMENT OF NOTARY PUBLIC 
STATE OF _______________ 
_____________ County, ss.  
On this ____ day of _______________________, 20___, before me appeared  ____________________, as Principal of this Power of Attorney who proved to me through  government issued photo identification to be the above-named person, in my presence  executed foregoing instrument and acknowledged that he executed the same as his free  act and deed. 
____________________________ 
Notary Public 
My commission expires:_________
                                                             Page 3 of 3