This document was executed on this _____ day of _____________, 20_____
I, (full legal name), being of sound mind and not acting under duress or undue influence, hereby appoint the person(s) named below as my Attorney-in-Fact (Agent) to act on my behalf.
Date of Birth:
Social Security Number:
Address:
City, State, ZIP:
Phone:
Email:
Primary Agent:
Name:
Relationship:
Address:
City, State, ZIP:
Phone:
Email:
Alternate Agent (if primary agent is unavailable):
Name:
Relationship:
Address:
City, State, ZIP:
Phone:
Email:
I grant my Attorney-in-Fact the following powers to act on my behalf:
Specify any limitations on the powers granted above:
Gift Limitations: My agent may make gifts not exceeding $ per person per year.
Select ONE option:
This power of attorney:
Select ONE option:
Please include any other specific instructions or wishes:
I understand the full import of this document and I am emotionally and mentally competent to execute this Power of Attorney. I understand that I may revoke this document at any time.
Signature of Principal:
Date:
We declare that the person who signed this document did so in our presence, that they appeared to be of sound mind and not under duress or undue influence, and that we are not the agent named in this document, nor related to the principal by blood or marriage.
Witness #1:
Signature:
Printed Name:
Address:
Date:
Witness #2:
Signature:
Printed Name:
Address:
Date:
STATE OF
COUNTY OF
On this _____ day of _____________, 20_____, before me personally appeared , known to me to be the person described in and who executed the foregoing instrument, and acknowledged that they executed the same as their free act and deed.
Notary Public:
My Commission Expires:
[NOTARY SEAL]