STATUTORY FORM LIMITED POWER OF ATTORNEY
PLEASE READ CAREFULLY
This power of attorney authorizes another person (your agent) to make decisions concerning your
property for you (the principal). You need not give to your agent all the authorities listed below
and may give the agent only those limited powers that you specifically indicate. This power of
attorney gives your agent the right to make limited decisions for you. You should very carefully
weigh your decision as to what powers you give your agent. Your agent will be able to make
decisions and act with respect to your property (including your money) whether or not you are
able to act for yourself.
If you choose to make a grant of limited authority, you should check the boxes that identify the
specific authorization you choose to give your agent.
This power of attorney does not authorize the agent to make health care decisions for you.
You should select someone you trust to serve as your agent. Unless you specify otherwise,
generally the agent’s authority will continue until you die or revoke the power of attorney or the
agent resigns or is unable to act for you.
Your agent is not entitled to compensation unless you indicate otherwise in the special
instructions of this power of attorney. If you indicate that your agent is to receive compensation,
your agent is entitled to reasonable compensation or compensation as specified in the Special
Instructions.
This form provides for designation of one agent. If you wish to name more than one agent you
may name a coagent in the Special Instructions. Coagents are required to act together
unanimously unless you specify otherwise in the Special Instructions.
If your agent is unavailable or unwilling to act for you, your power of attorney will end unless you
have named a successor agent. You may also name a second successor agent.
This power of attorney becomes effective immediately unless you state otherwise in the Special
Instructions.
If you have questions about the power of attorney or the authority you are granting to your agent,
you should seek legal advice before signing this form.

DESIGNATION OF AGENT
This section of the form provides for designation of one agent.
If you wish to name coagents, skip this section and use the next section (“Designation of
Coagents”).
I, __________ (Name of Principal), name the following person as my agent:
Name of Agent: __________
Agent’s Address: __________, __________, __________, __________ __________
Agent’s Telephone Number: __________

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DESIGNATION OF COAGENTS (OPTIONAL)
This section of the form provides for designation of two or more coagents. Coagents are required
to act together unanimously unless you otherwise provide in this form.
I, __________ [Name of Principal], name the following persons as coagents:
Name of Coagent: __________
Coagent’s Address: __________
Coagent’s Telephone Number: __________
Name of Coagent: __________
Coagent’s Address: __________
Coagent’s Telephone Number: __________
Special Instructions Regarding Coagents: __________

DESIGNATION OF SUCCESSOR AGENT(S) (OPTIONAL)
If my agent is unable or unwilling to act for me, I name as my successor agent:
Name of Successor Agent: __________
Successor Agent’s Address: __________, __________, __________ __________
Successor Agent’s Telephone Number: __________
If my successor agent is unable or unwilling to act for me, I name as my second successor agent:
Name of Second Successor Agent: __________
Second Successor Agent’s Address: __________, __________, __________ __________
Second Successor Agent’s Telephone Number: __________

GRANT OF GENERAL AUTHORITY
I (“the principal”) grant my agent and any successor agent, with respect to each subject that I
choose below, the authority to do all acts that I could do to:
(1) Demand, receive, and obtain by litigation or otherwise, money or another thing of value to
which the principal is, may become, or claims to be entitled, and conserve, invest, disburse, or
use anything so received or obtained for the purposes intended;
(2) Contract with another person, on terms agreeable to the agent, to accomplish a purpose of a
transaction and perform, rescind, cancel, terminate, reform, restate, release, or modify the
contract or another contract made by or on behalf of the principal;
(3) Execute, acknowledge, seal, deliver, file, or record any instrument or communication the
agent considers desirable to accomplish a purpose of a transaction, including creating a schedule
contemporaneously or at a later time listing some or all of the principal’s property and attaching
the schedule to this power of attorney;
(4) Initiate, participate in, submit to alternative dispute resolution, settle, oppose, or propose or
accept a compromise with respect to a claim existing in favor of or against the principal or
intervene in litigation relating to the claim;
(5) Seek on the principal’s behalf the assistance of a court or other governmental agency to
carry out an act authorized in this power of attorney;

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(6) Engage, compensate, and discharge an attorney, accountant, discretionary investment
manager, expert witness, or other advisor;
(7) Prepare, execute, and file a record, report, or other document to safeguard or promote the
principal’s interest under a statute or regulation;
(8) Communicate with representatives or employees of a government or governmental
subdivision, agency, or instrumentality, on behalf of the principal;
(9) Access communications intended for, and communicate on behalf of the principal, whether
by mail, electronic transmission, telephone, or other means; and
(10) Do lawful acts with respect to the subject and all property related to the subject.
(INITIAL each authority in any subject you want to include in the agent’s general authority. Cross
through each authority in any subject that you want to exclude. If you wish to grant general
authority over an entire subject, you may initial “All of the above” instead of initialing each
authority.)

SUBJECTS AND AUTHORITY
A. Real Property – With respect to this category, I authorize my agent to:
[ ] (_____) Demand, buy, lease, receive, accept as a gift or as security for an extension of
credit, or otherwise acquire or reject an interest in real property or a right incident to real property
[ ] (_____) Sell, exchange, convey with or without covenants, representations, or warranties,
quitclaim, release, surrender, retain title for security, encumber, partition, consent to partitioning,
subject to an easement or covenant, subdivide, apply for zoning or other governmental permits,
plat or consent to platting, develop, grant an option concerning, lease, sublease, contribute to an
entity in exchange for an interest in that entity, or otherwise grant or dispose of an interest in real
property or a right incident to real property
[ ] (_____) Pledge or mortgage an interest in real property or right incident to real property as
security to borrow money or pay, renew, or extend the time of payment of a debt of the principal
or a debt guaranteed by the principal, including a reverse mortgage
[ ] (_____) Release, assign, satisfy, or enforce by litigation or otherwise a mortgage, deed of
trust, conditional sale contract, encumbrance, lien, or other claim to real property that exists or is
asserted
[ ] (_____) Manage or conserve an interest in real property or a right incident to real property
owned or claimed to be owned by the principal, including:
(1) Insuring against liability or casualty or other loss;
(2) Obtaining or regaining possession of or protecting the interest or right by litigation or
otherwise;
(3) Paying, assessing, compromising, or contesting taxes or assessments or applying for and
receiving refunds in connection with them; and
(4) Purchasing supplies, hiring assistance or labor, and making repairs or alterations to the real
property
[ ] (_____) Use, develop, alter, replace, remove, erect, or install structures or other
improvements on real property in or incident to which the principal has, or claims to have, an
interest or right

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[ ] (_____) Participate in a reorganization with respect to real property or an entity that owns
an interest in or a right incident to real property and receive, hold, and act with respect to stocks
and bonds or other property received in a plan of reorganization, including:
(1) Selling or otherwise disposing of the stocks and bonds or other property;
(2) Exercising or selling an option, a right of conversion, or a similar right with respect to the
stocks and bonds or other property; and
(3) Exercising voting rights in person or by proxy
[

] (_____) Change the form of title of an interest in or a right incident to real property

[ ] (_____) Dedicate to public use, with or without consideration, easements or other real
property in which the principal has, or claims to have, an interest
[

] (_____) All of the above

B. Tangible Personal Property – With respect to this subject, I authorize my agent to:
[ ] (_____) Demand, buy, receive, accept as a gift or as security for an extension of credit, or
otherwise acquire or reject ownership or possession of tangible personal property or an interest in
tangible personal property
[ ] (_____) Sell, exchange, convey with or without covenants, representations, or warranties,
quitclaim, release, surrender, create a security interest in, grant options concerning, lease,
sublease, or otherwise dispose of tangible personal property or an interest in tangible personal
property
[ ] (_____) Grant a security interest in tangible personal property or an interest in tangible
personal property as security to borrow money or pay, renew, or extend the time of payment of a
debt of the principal or a debt guaranteed by the principal
[ ] (_____) Release, assign, satisfy, or enforce by litigation or otherwise, a security interest,
lien, or other claim on behalf of the principal, with respect to tangible personal property or an
interest in tangible personal property
[ ] (_____) Manage or conserve tangible personal property or an interest in tangible personal
property on behalf of the principal, including:
(1) Insuring against liability or casualty or other loss;
(2) Obtaining or regaining possession of or protecting the property or interest, by litigation or
otherwise;
(3) Paying, assessing, compromising, or contesting taxes or assessments or applying for and
receiving refunds in connection with taxes or assessments;
(4) Moving the property from place to place;
(5) Storing the property for hire or on a gratuitous bailment; and
(6) Using and making repairs, alterations, or improvements to the property
[

] (_____) Change the form of title of an interest in tangible personal property

[

] (_____) All of the above

C. Stocks and Bonds – With respect to this subject, I authorize my agent to:
[

] (_____) Buy, sell, and exchange stocks and bonds

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[ ] (_____) Establish, continue, modify, or terminate an account with respect to stocks and
bonds
[ ] (_____) Pledge stocks and bonds as security to borrow, pay, renew, or extend the time of
payment of a debt of the principal
[ ] (_____) Receive certificates and other evidences of ownership with respect to stocks and
bonds
[ ] (_____) Exercise voting rights with respect to stocks and bonds in person or by proxy, enter
into voting trusts, and consent to limitations on the right to vote
[

] (_____) All of the above

D. Commodities – With respect to this subject, I authorize my agent to:
[ ] (_____) Buy, sell, exchange, assign, settle, and exercise commodity futures contracts and
call or put options on stocks or stock indexes traded on a regulated option exchange
[

] (_____) Establish, continue, modify, and terminate option accounts

[

] (_____) All of the above

E. Banks and Other Financial Institutions – With respect to this subject, I authorize my agent
to:
[ ] (_____) Continue, modify, transact all business in connection with, and terminate an
account or other banking arrangement made by or on behalf of the principal
[ ] (_____) Establish, modify, transact all business in connection with, and terminate an
account or other banking arrangement with a bank, trust company, savings and loan association,
credit union, thrift company, brokerage firm, or other financial institution selected by the agent
[ ] (_____) Contract for services available from a financial institution, including renting a safe
deposit box or space in a vault
[ ] (_____) Deposit by check, money order, electronic funds transfer, or otherwise with, or
leave in the custody of, a financial institution money or property of the principal
[ ] (_____) Withdraw, by check, money order, electronic funds transfer, or otherwise, money or
property of the principal deposited with or left in the custody of a financial institution
[ ] (_____) Receive statements of account, vouchers, notices, and similar documents from a
financial institution and act with respect to them
[

] (_____) Enter a safe deposit box or vault and withdraw or add to the contents

[ ] (_____) Borrow money and pledge as security personal property of the principal necessary
to borrow money or pay, renew, or extend the time of payment of a debt of the principal or a debt
guaranteed by the principal
[ ] (_____) Make, assign, draw, endorse, discount, guarantee, and negotiate promissory notes,
checks, drafts, and other negotiable or nonnegotiable paper of the principal or payable to the
principal or the principal’s order, transfer money, receive the cash or other proceeds of those
transactions, and accept a draft drawn by a person on the principal and pay the draft when due

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[ ] (_____) Receive for the principal and act on a sight draft, warehouse receipt, other
document of title whether tangible or electronic, or other negotiable or nonnegotiable instrument
[ ] (_____) Apply for, receive, and use letters of credit, credit cards and debit cards, electronic
transaction authorizations, and traveler’s checks from a financial institution and give an indemnity
or other agreement in connection with letters of credit
[ ] (_____) Consent to an extension of the time of payment with respect to commercial paper
or a financial transaction with a financial institution
[

] (_____) All of the above

F. Operation of an Entity or a Business – With respect to this subject, I authorize my agent to:
[

] (_____) Operate, buy, sell, enlarge, reduce, or terminate an ownership interest

[ ] (_____) Perform a duty or discharge a liability and exercise in person or by proxy a right,
power, privilege, or an option that the principal has, may have, or claims to have
[

] (_____) Enforce the terms of an ownership agreement

[ ] (_____) Initiate, participate in, submit to alternative dispute resolution, settle, oppose, or
propose or accept a compromise with respect to litigation to which the principal is a party
because of an ownership interest
[ ] (_____) Exercise in person or by proxy, or enforce by litigation or otherwise, a right, power,
privilege, or an option the principal has or claims to have as the holder of stocks and bonds
[ ] (_____) Initiate, participate in, submit to alternative dispute resolution, settle, oppose, or
propose or accept a compromise with respect to litigation to which the principal is a party
concerning stocks and bonds
[ ] (_____) With respect to an entity or business owned solely by the principal:
(1) Continue, modify, renegotiate, extend, and terminate a contract made by or on behalf of the
principal with respect to the entity or business before execution of this power of attorney;
(2) Determine:
(i) The location of the operation of the entity or business;
(ii) The nature and extent of the business of the entity or business;
(iii) The methods of manufacturing, selling, merchandising, financing, accounting, and
advertising employed in the operation of the entity or business;
(iv) The amount and types of insurance carried by the entity or business; and
(v) The mode of engaging, compensating, and dealing with the employees and accountants,
attorneys, or other advisors of the entity or business;
(3) Change the name or form of organization under which the entity or business is operated and
enter into an ownership agreement with other persons to take over all or part of the operation of
the entity or business; and
(4) Demand and receive money due or claimed by the principal or on the principal’s behalf in the
operation of the entity or business and control and disburse the money in the operation of the
entity or business
[ ] (_____) Put additional capital into an entity or a business in which the principal has an
interest
[ ] (_____) Join in a plan of reorganization, consolidation, conversion, domestication, or
merger of the entity or business

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[

] (_____) Sell or liquidate all or part of an entity or business

[ ] (_____) Establish the value of an entity or a business under a buyout agreement to which
the principal is a party
[ ] (_____) Prepare, sign, file, and deliver reports, compilations of information, returns, or other
papers with respect to an entity or business and make related payments
[ ] (_____) Pay, compromise, or contest taxes, assessments, fines, or penalties and perform
other acts to protect the principal from illegal or unnecessary taxation, assessments, fines, or
penalties, with respect to an entity or a business, including attempts to recover, as permitted by
law, money paid before or after the execution of this power of attorney
[

] (_____) All of the above

G. Insurance and Annuities – With respect to this subject, I authorize my agent to:
[ ] (_____) Continue, pay the premium or make a contribution on, modify, exchange, rescind,
release, or terminate a contract procured by or on behalf of the principal that insures or provides
an annuity to either the principal or another person, whether or not the principal is a beneficiary
under the contract
[ ] (_____) Procure new, different, and additional contracts of insurance and annuities for the
principal and the principal’s spouse, children, and other dependents, and select the amount, type
of insurance or annuity, and mode of payment
[ ] (_____) Pay the premium or make a contribution on, modify, exchange, rescind, release, or
terminate a contract of insurance or annuity procured by the agent
[

] (_____) Apply for and receive a loan secured by a contract of insurance or annuity

[ ] (_____) Surrender and receive the cash surrender value on a contract of insurance or
annuity
[

] (_____) Exercise an election

[

] (_____) Exercise investment powers available under a contract of insurance or annuity

[

] (_____) Change the manner of paying premiums on a contract of insurance or annuity

[ ] (_____) Change or convert the type of insurance or annuity with respect to which the
principal has or claims to have authority described in this section
[ ] (_____) Apply for and procure a benefit or assistance under a statute or regulation to
guarantee or pay premiums of a contract of insurance on the life of the principal
[ ] (_____) Collect, sell, assign, hypothecate, borrow against, or pledge the interest of the
principal in a contract of insurance or annuity
[ ] (_____) Select the form and timing of the payment of proceeds from a contract of insurance
or annuity
[ ] (_____) Pay, from proceeds or otherwise, compromise or contest, and apply for refunds in
connection with a tax or assessment levied by a taxing authority with respect to a contract of

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insurance or annuity or the proceeds or liability from the contract of insurance or annuity accruing
by reason of the tax or assessment
[

] (_____) All of the above

H. Estates, Trusts, and Other Beneficial Interests (including trusts, probate estates,
guardianships, conservatorships, escrows, or custodianships or funds from which the principal is,
may become, or claims to be entitled to a share or payment) – With respect to this subject, I
authorize my agent to:
[ ] (_____) Accept, receive, receipt for, sell, assign, pledge, or exchange a share in or payment
from the fund described above
[ ] (_____) Demand or obtain money or another thing of value to which the principal is, may
become, or claims to be entitled by reason of the fund described above, by litigation or otherwise
[ ] (_____) Exercise for the benefit of the principal a presently exercisable general power of
appointment held by the principal
[ ] (_____) Initiate, participate in, submit to alternative dispute resolution, settle, oppose, or
propose or accept a compromise with respect to litigation to ascertain the meaning, validity, or
effect of a deed, will, declaration of trust, or other instrument or transaction affecting the interest
of the principal
[ ] (_____) Initiate, participate in, submit to alternative dispute resolution, settle, oppose, or
propose or accept a compromise with respect to litigation to remove, substitute, or surcharge a
fiduciary
[

] (_____) Conserve, invest, disburse, or use anything received for an authorized purpose

[ ] (_____) Transfer an interest of the principal in real property, stocks and bonds, accounts
with financial institutions or securities intermediaries, insurance, annuities, and other property to
the trustee of a revocable trust created by the principal as settlor
[ ] (_____) Reject, renounce, disclaim, release, or consent to a reduction in or modification of a
share in or payment from the fund described above
[

] (_____) All of the above

I. Claims and Litigation – With respect to this subject, I authorize my agent to:
[ ] (_____) Assert and maintain before a court or administrative agency a claim, claim for relief,
cause of action, counterclaim, offset, recoupment, or defense, including an action to recover
property or other thing of value, recover damages sustained by the principal, eliminate or modify
tax liability, or seek an injunction, specific performance, or other relief
[ ] (_____) Bring an action to determine adverse claims or intervene or otherwise participate in
litigation
[ ] (_____) Seek an attachment, garnishment, order of arrest, or other preliminary, provisional,
or intermediate relief and use an available procedure to effect or satisfy a judgment, order, or
decree

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[ ] (_____) Make or accept a tender, offer of judgment, or admission of facts, submit a
controversy on an agreed statement of facts, consent to examination, and bind the principal in
litigation
[ ] (_____) Submit to alternative dispute resolution, settle, and propose or accept a
compromise
[ ] (_____) Waive the issuance and service of process on the principal, accept service of
process, appear for the principal, designate persons on which process directed to the principal
may be served, execute and file or deliver stipulations on the principal’s behalf, verify pleadings,
seek appellate review, procure and give surety and indemnity bonds, contract and pay for the
preparation and printing of records and briefs, receive, execute, and file or deliver a consent,
waiver, release, confession of judgment, satisfaction of judgment, notice, agreement, or other
instrument in connection with the prosecution, settlement, or defense of a claim or litigation
[ ] (_____) Act for the principal with respect to bankruptcy or insolvency, whether voluntary or
involuntary, concerning the principal or some other person, or with respect to a reorganization,
receivership, or application for the appointment of a receiver or trustee that affects an interest of
the principal in property or other thing of value
[ ] (_____) Pay a judgment, award, or order against the principal or a settlement made in
connection with a claim or litigation
[ ] (_____) Receive money or other thing of value paid in settlement of or as proceeds of a
claim or litigation
[

] (_____) All of the above

J. Personal and Family Maintenance – With respect to this subject, I authorize my agent to:
[ ] (_____) Perform the acts necessary to maintain the customary standard of living of the
principal, the principal’s spouse, and the following individuals, whether living when this power of
attorney is executed or later born:
(1) The principal’s children;
(2) Other individuals legally entitled to be supported by the principal; and
(3) The individuals whom the principal has customarily supported or indicated the intent to
support;
[ ] (_____) Make periodic payments of child support and other family maintenance required by
a court or governmental agency or an agreement to which the principal is a party
[ ] (_____) Provide living quarters for the individuals described above by:
(1) Purchase, lease, or other contract; or
(2) Paying the operating costs, including interest, amortization payments, repairs,
improvements, and taxes, for premises owned by the principal or occupied by those individuals
[ ] (_____) Provide normal domestic help, usual vacations and travel expenses, and funds for
shelter, clothing, food, appropriate education, including postsecondary and vocational education,
and other current living costs for the individuals described above
[ ] (_____) Pay expenses for necessary health care and custodial care on behalf of the
individuals described above
[ ] (_____) Act as the principal’s personal representative in accordance with the Health
Insurance Portability and Accountability Act, §§ 1171 through 1179 of the Social Security Act, 42
U.S.C. § 1320d, and applicable regulations in making decisions related to the past, present, or

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future payment for the provision of health care consented to by the principal or anyone authorized
under the law of this State to consent to health care on behalf of the principal
[ ] (_____) Continue provisions made by the principal for automobiles or other means of
transportation, including registering, licensing, insuring, and replacing the means of
transportation, for the individuals described above
[ ] (_____) Maintain credit and debit accounts for the convenience of the individuals described
above and open new accounts
[ ] (_____) Continue payments incidental to the membership or affiliation of the principal in a
religious institution, club, society, order, or other organization or to continue contributions to those
organizations
(NOTE: Authority with respect to personal and family maintenance is neither dependent on, nor
limited by, authority that an agent may or may not have with respect to gifts under this power of
attorney.)
[

] (_____) All of the above

K. Benefits from Governmental Programs or Civil or Military Service (including any benefit,
program, or assistance provided under a statute or regulation including Social Security, Medicare,
and Medicaid) – With respect to this subject, I authorize my agent to:
[ ] (_____) Execute vouchers in the name of the principal for allowances and reimbursements
payable by the United States or a foreign government or by a state or subdivision of a state to the
principal, including allowances and reimbursements for transportation of the individuals described
in “J. Personal and Family Maintenance” above, and for shipment of the household effects of
those individuals
[ ] (_____) Take possession and order the removal and shipment of property of the principal
from a post, warehouse, depot, dock, or other place of storage or safekeeping, either
governmental or private, and execute and deliver a release, voucher, receipt, bill of lading,
shipping ticket, certificate, or other instrument for that purpose
[ ] (_____) Enroll in, apply for, select, reject, change, amend, or discontinue, on the principal’s
behalf, a benefit or program
[ ] (_____) Prepare, file, and maintain a claim of the principal for a benefit or assistance,
financial or otherwise, to which the principal may be entitled under a statute or regulation
[ ] (_____) Initiate, participate in, submit to alternative dispute resolution, settle, oppose, or
propose or accept a compromise with respect to litigation concerning a benefit or assistance the
principal may be entitled to receive under a statute or regulation
[ ] (_____) Receive the financial proceeds of a claim described above and conserve, invest,
disburse, or use for a lawful purpose anything so received
[

] (_____) All of the above

L. Retirement Plans (including a plan or account created by an employer, the principal, or
another individual to provide retirement benefits or deferred compensation of which the principal
is a participant, beneficiary, or owner, including a plan or account under the following sections of
the Internal Revenue Code:

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(1) An individual retirement account under Internal Revenue Code Section 408, 26 U.S.C. §
408;
(2) A Roth individual retirement account under Internal Revenue Code Section 408A, 26 U.S.C.
§ 408A;
(3) A deemed individual retirement account under Internal Revenue Code Section 408(q), 26
U.S.C. § 408(q);
(4) An annuity or mutual fund custodial account under Internal Revenue Code Section 403(b),
26 U.S.C. § 403(b);
(5) A pension, profit–sharing, stock bonus, or other retirement plan qualified under Internal
Revenue Code Section 401(a), 26 U.S.C. § 401(a);
(6) A plan under Internal Revenue Code Section 457(b), 26 U.S.C. § 457(b); and
(7) A nonqualified deferred compensation plan under Internal Revenue Code Section 409A, 26
U.S.C. § 409A) – With respect to this subject, I authorize my agent to:
[ ] (_____) Select the form and timing of payments under a retirement plan and withdraw
benefits from a plan
[ ] (_____) Make a rollover, including a direct trustee–to–trustee rollover, of benefits from one
retirement plan to another
[

] (_____) Establish a retirement plan in the principal’s name

[

] (_____) Make contributions to a retirement plan

[

] (_____) Exercise investment powers available under a retirement plan

[

] (_____) Borrow from, sell assets to, or purchase assets from a retirement plan

[

] (_____) All of the above

M. Taxes – With respect to this subject, I authorize my agent to:
[ ] (_____) Prepare, sign, and file federal, state, local, and foreign income, gift, payroll,
property, Federal Insurance Contributions Act, and other tax returns, claims for refunds, requests
for extension of time, petitions regarding tax matters, and other tax–related documents, including
receipts, offers, waivers, consents, including consents and agreements under Internal Revenue
Code Section 2032A, 26 U.S.C. § 2032A, closing agreements, and other powers of attorney
required by the Internal Revenue Service or other taxing authority with respect to a tax year on
which the statute of limitations has not run and the following 25 tax years
[ ] (_____) Pay taxes due, collect refunds, post bonds, receive confidential information, and
contest deficiencies determined by the Internal Revenue Service or other taxing authority
[ ] (_____) Exercise elections available to the principal under federal, state, local, or foreign
tax law
[ ] (_____) Act for the principal in all tax matters for all periods before the Internal Revenue
Service, or other taxing authority
[

] (_____) All of the above

N. Gifts (including gifts to a trust, an account under the Uniform Transfers to Minors Act, and a
tuition savings account or prepaid tuition plan as defined under Internal Revenue Code Section
529, 26 U.S.C. § 529) – With respect to this subject, I authorize my agent to:

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[ ] (_____) Make outright to, or for the benefit of, a person, a gift of part or all of the principal’s
property, including by the exercise of a presently exercisable general power of appointment held
by the principal, in an amount for each donee not to exceed the annual dollar limits of the federal
gift tax exclusion under Internal Revenue Code Section 2503(b), 26 U.S.C. § 2503(b), without
regard to whether the federal gift tax exclusion applies to the gift, or if the principal’s spouse
agrees to consent to a split gift pursuant to Internal Revenue Code Section 2513, 26 U.S.C. §
2513, in an amount for each donee not to exceed twice the annual federal gift tax exclusion limit
[ ] (_____) Consent, pursuant to Internal Revenue Code Section 2513, 26 U.S.C. § 2513, to
the splitting of a gift made by the principal’s spouse in an amount for each donee not to exceed
the aggregate annual gift tax exclusions for both spouses
(NOTE: An agent may only make a gift of the principal’s property as the agent determines is
consistent with the principal’s objectives if actually known by the agent and, if unknown, as the
agent determines is consistent with the principal’s best interest based on all relevant factors,
including:
(1) The value and nature of the principal’s property;
(2) The principal’s foreseeable obligations and need for maintenance;
(3) Minimization of taxes, including income, estate, inheritance, generation–skipping transfer,
and gift taxes;
(4) Eligibility for a benefit, a program, or assistance under a statute or regulation; and
(5) The principal’s personal history of making or joining in making gifts.)
[

] (_____) All of the above

GRANT OF SPECIFIC AUTHORITY (OPTIONAL)
My agent MAY NOT do any of the following specific acts for me UNLESS I have INITIALED the
specific authority listed below:
(CAUTION: Granting any of the following will give your agent the authority to take actions that
could significantly reduce your property or change how your property is distributed at your death.
In addition, granting your agent the authority to make gifts to, or to designate as the beneficiary of
any retirement plan, the agent, the agent’s spouse, or a dependent of the agent may constitute a
taxable gift by you and may make the property subject to that authority taxable as part of the
agent’s estate. INITIAL ONLY the specific authority you WANT to give your agent.)
[ ] (_____) Create an inter vivos trust, or amend, revoke, or terminate an existing inter vivos
trust if the trust expressly authorizes that action by the agent
[ ] (_____) Make a gift, subject to any special instructions in this power of attorney
[ ] (_____) Create or change rights of survivorship
[ ] (_____) Create or change a beneficiary designation, subject to any special instructions in
this power of attorney; and, if I wish to authorize my agent to designate the agent, the agent’s
spouse, or a dependent of the agent as a beneficiary, I will explicitly state this authority within the
special instructions of this power of attorney or in a separate power of attorney
[ ] (_____) Authorize another person to exercise the authority granted under this power of
attorney
[ ] (_____) Waive the principal’s right to be a beneficiary of a joint and survivor annuity,
including a survivor benefit under a retirement plan
[ ] (_____) Exercise fiduciary powers that the principal has authority to delegate
[ ] (_____) Disclaim or refuse an interest in property, including a power of appointment

LIMITATION ON AGENT’S AUTHORITY

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An agent that is not my ancestor, spouse, or descendant MAY NOT use my property to benefit
the agent or a person to whom the agent owes an obligation of support unless I have included
that authority in the Special Instructions.
SPECIAL INSTRUCTIONS (OPTIONAL)
You may give special instructions on the following lines:
________________________________________________________________________
_________________________________________________________________________
EFFECTIVE DATE
This power of attorney is effective immediately unless I have stated otherwise in the Special
Instructions.

TERMINATION DATE (OPTIONAL)
This power of attorney shall terminate on _________ ______, 20___.. (Use a specific calendar
date)

NOMINATION OF GUARDIAN (OPTIONAL)
If it becomes necessary for a court to appoint a guardian of my property or guardian of my
person, I nominate the following person(s) for appointment:
Name of Nominee for guardian of my property: __________
Nominee’s Address:__________, __________, __________, __________
Nominee’s Telephone Number: __________
Name of Nominee for guardian of my person: __________
Nominee’s Address:__________, __________, __________, __________
Nominee’s Telephone Number: __________

SIGNATURE AND ACKNOWLEDGMENT OF PRINCIPAL
Your Signature___________________________

Date________________________

Your Name Printed: __________
Your Address: __________, __________, __________, __________ __________
Your Telephone Number: __________
STATE OF ______________
(COUNTY) OF ______________
This document was acknowledged before me on
_________________[Date], by ______________________[Name of Principal].
_______________________________________ Signature of Notary
My commission expires:___________________

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(Seal, if any)

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WITNESS ATTESTATION
The foregoing power of attorney was, on the date written above, published and declared by
______________[Name of Principal] in our presence to be his/her power of attorney. We, in
his/her presence and at his/her request, and in the presence of each other, have attested to the
same and have signed our names as attesting witnesses.
__________________________________
__________________________________
Witness #1 Signature
Witness #1 Name Printed
____________________________________________________________________
Witness #1 Address
___________________________
Witness #1 Telephone Number
__________________________________
__________________________________
Witness #2 Signature
Witness #2 Name Printed
____________________________________________________________________
Witness #2 Address
___________________________
Witness #2 Telephone Number
This document prepared by: __________

IMPORTANT INFORMATION FOR AGENT
Agent’s Duties
When you accept the authority granted under this power of attorney, a special legal relationship is
created between you and the principal. This relationship imposes on you legal duties that
continue until you resign or the power of attorney is terminated or revoked. You must:
(1) Do what you know the principal reasonably expects you to do with the principal’s property or,
if you do not know the principal’s expectations, act in the principal’s best interest;
(2) Act with care, competence, and diligence for the best interest of the principal;
(3) Do nothing beyond the authority granted in this power of attorney; and
(4) Disclose your identity as an agent whenever you act for the principal by writing or printing the
name of the principal and signing your own name as “agent” in the following manner:
_______________ (Principal’s Name) by _______________ (Your Signature) as Agent
Unless the Special Instructions in this power of attorney state otherwise, you must also:
(1) Act loyally for the principal’s benefit;
(2) Avoid conflicts that would impair your ability to act in the principal’s best interest;
(3) Keep a record of all receipts, disbursements, and transactions made on behalf of the
principal;
(4) Cooperate with any person that has authority to make health care decisions for the principal
to do what you know the principal reasonably expects or, if you do not know the principal’s
expectations, to act in the principal’s best interest; and
(5) Attempt to preserve the principal’s estate plan if you know the plan and preserving the plan
is consistent with the principal’s best interest.
Termination of Agent’s Authority
You must stop acting on behalf of the principal if you learn of any event that terminates this power
of attorney or your authority under this power of attorney. Events that terminate a power of
attorney or your authority to act under a power of attorney include:

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(1) Death of the principal;
(2) The principal’s revocation of the power of attorney or your authority;
(3) The occurrence of a termination event stated in the power of attorney;
(4) The purpose of the power of attorney is fully accomplished; or
(5) If you are married to the principal, a legal action is filed with a court to end your marriage, or
for your legal separation, unless the Special Instructions in this power of attorney state that such
an action will not terminate your authority.
Liability of Agent
The meaning of the authority granted to you is defined in the [State Name] Power of Attorney Act,
Title 17 of the Estates and Trusts Article. If you violate the [State Name] Power of Attorney Act,
Title 17 of the Estates and Trusts Article, or act outside the authority granted, you may be liable
for any damages caused by your violation.
If there is anything about this document or your duties that you do not understand, you should
seek legal advice.

AGENT'S CERTIFICATION AS TO THE VALIDITY OF POWER OF ATTORNEY AND AGENT'S
AUTHORITY
State of _________________________
County of __________
I, __________ (Name of Agent), certify under penalty of perjury that __________ (Name of
Principal) granted me authority as an agent or successor agent in a power of attorney dated
_________________________.
I, further certify that to my knowledge:
(1) The Principal is alive and has not revoked the power of attorney or my authority to act under
the power of attorney and the power of attorney and my authority to act under the power of
attorney have not terminated;
(2) If the power of attorney was drafted to become effective upon the happening of an event or
contingency, the event or contingency has occurred;
(3) If I was named as a successor agent, the prior agent is no longer able or willing to serve; and
(4) ______________________________________________________________
___________________________________ (Insert other relevant statements)

SIGNATURE AND ACKNOWLEDGMENT OF AGENT
Agent’s Signature____________________________

Date________________________

Agent's Name Printed: __________
Agent's Address: __________, __________, __________, __________ __________
Agent's Telephone Number: __________
This document was acknowledged before me on
_________________________ (Date), by __________ (Name of Agent).
Signature of Notary _________________________

(Seal, if any)

My commission expires: _________________________

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This document prepared by: __________

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GENERAL INSTRUCTIONS
W HAT IS A POW ER OF ATTORNEY?
A Power of Attorney is a written document that officially
recognizes a legally binding relationship between two
parties-- a Principal and an Agent. The Agent is given
power to manage the personal, business, or legal affairs
of the Principal. Further, the Agent has a fiduciary duty to
act in the Principal’s best financial interest and in
accordance with their wishes.
A simple Power of Attorney will identify the following
basic elements:
- Agent(s): someone responsible and trusted to act on
another person’s behalf
- Principal: the person wanting assistance with personal,
business, or legal matters
- Grant of Authority: the Agent has general or specific
authority to take certain actions
- Effective Date: when the Power of Attorney begins,
usually immediately
- Signatures: the Principal and a Notary must sign the
Power of Attorney
W HEN IS IT NEEDED?
Power of Attorneys or POAs are commonly used when
someone wants the peace of mind that their financial
or health decisions will be made by someone they
trust.
You may need a Power of Attorney if you are:
- Over the age of 18 years old
- Military personnel being deployed overseas
- Traveling abroad for an extended period of time
- Diagnosed with a chronic condition or life threatening
illness
- Growing wiser and older but concerned about your
current health
- Married and want your spouse to have legal authority
over property you own
- Engaged in a high risk profession (i.e. emergency
firefighter or member of police force)
W HAT K IND OF GENER AL POW ERS CAN
YOU GIVE YOUR AGENT?
Some of the general powers you can grant to your
Agent include managing the following: real property,
tangible personal property, stocks and bonds,
commodities and options, banks and other financial
institutions, insurance, estates and trusts, and

Power of Attorney (Rev. 1339ED7)

W HEN SHOULD A POW ER OF ATTORNEY
BEGIN?
Depending on your circumstances, you may want your
Agent to begin acting on your behalf immediately (i.e.
Durable Power of Attorney) or later (i.e. Springing
Power of Attorney).
W HEN DOES A POW ER OF ATTORNEY END?
A conventional or ordinary Power of Attorney ends
when you become incapacitated. In contrast, a Durable
Power of Attorney allows the Agent to continue acting
on behalf of the Principal even when they become
incapacitated.
W HAT K IND OF MATTERS C AN A POW ER OF
ATTORNEY CONTROL?
A Power of Attorney can be used to handle nonmedical matters (i.e. Financial Power of Attorney) or
health care decisions (i.e. Health Care Power of
Attorney). Most individuals have a separate Power of
Attorney for general matters and health care issues.
Many states, however, combine the a Living Will and
Power of Attorney into one “advance directive” form. A
Power of Attorney for Health Care allows you to name
your health agent, someone who will make health
decisions for you if you cannot. Your health care agent
will also ensure that your health care providers give
you the care you wish to receive. You can also require
that your health care agent communicate in any
manner with you about any specific proposed health
care. For example, you may still be able to
communicate by blinking your eyes.
W HAT H APPENS IF I DO NOT H AVE A
POWER OF ATTORNEY?
Without a Power of Attorney, even if you have a
spouse, the court may need to step in and appoint a
guardian or conservator for you if you ever become
incapacitated. The process of appointing a guardian is
costly and requires the guardian to formally report your
situation to the court each year. CNN Money estimates
that the process of obtaining a court appointed
guardian exceeds $1,000. Instead, a Power of Attorney
allows you to take back control and proactively choose
who YOU want to represent your best interests.

operation of businesses.

Power of Attorney (Rev. 1339ED7)