Who are you GIVING power of attorney to? A spouse or partnerA parent or family memberA child (adult child)A friend or trusted individualOther Who is this Power of Attorney for? First Last The "Principal" also known as the individual GIVING financial powers to another person. Mailing Address Principal's Address Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Agent Who will be RECEIVING powers to act on the Principal's behalf? First Last Also known as the "Agent" or "Attorney-in-Fact" Agent's Address Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code 2nd Agent Will there be a 2nd Agent? Will there be a 2nd Agent? YesNo A 2nd Agent is used in the chance the Agent is not able to act in the presence of the Principal. 2nd Agent's Name First Last Will there be a 3rd Agent? Will there be a 3rd Agent? YesNo The 3rd Agent would only be able to act in the presence of the Principal if the Agent and 2nd Agent are not available. 3rd Agent's Name First Last Designation of Other Agents Does the Principal want to allow the Agent to be able to designate other Agents? Does the Principal want to allow the Agent to be able to designate other Agents? YesNo This allows the Agent to have someone they trust to be able to act in the presence of the Principal if they are not allowed to do so themselves. Agent Powers The Agent(s) will have the power to: (check all that apply) The Agent(s) will have the power to: (check all that apply) Real PropertyTangible Personal PropertyStocks and BondsCommodities and OptionsBanks and Other Financial InstitutionsOperation of EntityInsurance and AnnuitiesEstates, Trusts, and Other Beneficial InterestsClaims and LitigationPersonal and Family MaintenanceBenefits from Governmental Programs or Civil or Military ServiceRetirement PlansTaxes Other Powers Select which OTHER POWERS the Agent will have: (check all that apply) Select which OTHER POWERS the Agent will have: (check all that apply) Make giftsCreate or change rights of survivorshipCreate or change a beneficiary designationAuthorize another person to exercise the authority granted under this power of attorneyWaive my right to be a Beneficiary of a joint or survivor annuity, including a survivor benefit under a retirement planExercise fiduciary powers that I have authority to delegateDisclaim or refuse an interest in property, including a power of appointmentAccess the content of electronic communications Additional Powers Are there any ADDITIONAL POWERS the Principal would like to give the Agent? Are there any ADDITIONAL POWERS the Principal would like to give the Agent? YesNo Write the Powers the Principal wishes to give the Agent: Guardianship Does the Principal want the Agent to be the Guardian of their Estate? Does the Principal want the Agent to be the Guardian of their Estate? YesNo A guardian (guardianship or conservatorship) of the estate is charged with the ward's property and financial affairs. Effective Date When does the Power of Attorney go into effect? When does the Power of Attorney go into effect? Effective immediately upon signingAt a later dateUpon the Principal's incapacity Enter the effective date: Notary Public Under North Carolina law, this document is REQUIRED to be signed in front of a Notary Public Under North Carolina law, this document is REQUIRED to be signed in front of a Notary Public I Understand Next Save Save and finish later
