Who are you GIVING power of attorney to? A spouse or partnerA parent or family memberA child (adult child)A friend or trusted individualOther Enter the name of the person GIVING power of attorney (the Principal): First Last The "Principal" also known as the individual GIVING financial powers to another person. Mailing Address Principal's Mailing Address Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Who will be RECEIVING powers to act on the Principal's behalf? First Last This is also known as the "Agent" or "Attorney-in-Fact" Mailing Address of the Agent Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Please enter your address. 2nd Agent Does the Principal want to elect a 2nd Agent? Does the Principal want to elect a 2nd Agent? YesNo If any Agent shall die, become incompetent, resign or refuse to accept the office of Agent, this is a person that will be able to act in the Principal's place. Name of 2nd Agent First Last 2nd 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 Banking Will the Agent have the right to Access the Principal's Bank Accounts? Will the Agent have the right to Access the Principal's Bank Accounts? YesNo To receive and deposit funds with any financial institution, and to withdraw funds by check or otherwise to pay for goods, services, and any other personal and business expenses for my benefit. If necessary to effect my Agent's powers, my Agent is authorized to execute any document required to be signed by such banking institution. Taxes Will the Agent have the Power to pay and file Taxes? Will the Agent have the Power to pay and file Taxes? YesNo To complete and sign any local, state and federal tax returns on the Principal's behalf, pay any taxes or assessments due and receive credits and refunds owed to the Principal and to sign any tax agency documents necessary to effectuate these powers. Safe Deposit Box(es) Will the Agent be able to have access to any Safe Deposit Boxes? Will the Agent be able to have access to any Safe Deposit Boxes? YesNo To have access at any time or times to any safe-deposit box rented by the Principal or to which they may have access, wheresoever located, including drilling, if necessary, and to remove all or any part of the contents thereof. Loans Will the Agent be able to make loans, promissory notes, or borrow money on the Principal's behalf? Will the Agent be able to make loans, promissory notes, or borrow money on the Principal's behalf? YesNo The Agent will be able to make loans in the Principal's name; borrow money, individually or jointly with others; to give promissory notes or other obligations therefor; and to deposit or mortgage as collateral or for security for the payment thereof any or all securities, real estate, personal property, or other property of whatever nature and wherever situated, held by the Principal personally or in trust for their benefit. Government Benefits Will the Agent have powers over Government Benefits? Will the Agent have powers over Government Benefits? YesNo Such as Social Security, Medicare, Medicaid, and any Military Benefits. The Agent will also have the rights to enroll, amend, or terminate Government programs. Retirement Accounts Will the Agent have the Power of the Principal's Retirement Plans? Will the Agent have the Power of the Principal's Retirement Plans? YesNo To contribute to, select payment option of, roll-over, and receive benefits of any retirement plan or IRA the Principal may own, except the Agent shall not have power to change the beneficiary of any of my retirement plans or IRAs. Real Estate Will the Agent have Power over the Principal's Real Estate holdings? Will the Agent have Power over the Principal's Real Estate holdings? YesNo To acquire, purchase, exchange, lease, grant options to sell, and sell and convey real property, or any interests therein, on such terms and conditions, including credit arrangements, as the Agent shall deem proper; to execute, acknowledge and deliver, under seal or otherwise, any and all assignments, transfers, deeds, papers, documents or instruments which the Agent shall deem necessary in connection therewith. Personal Property Will the Agent be able to Buy or Sell Personal Property? Will the Agent be able to Buy or Sell Personal Property? YesNo To acquire, purchase, exchange, lease, grant options to sell, and sell and convey personal property, or any interests therein, on such terms and conditions, including credit arrangements, as the Agent shall deem proper; to execute, acknowledge and deliver, under seal or otherwise, any and all assignments, transfers, titles, papers, documents or instruments which the Agent shall deem necessary. Stocks & Bonds Will the Agent have the Power to Buy, Sell, or Exchange Stocks and Bonds? Will the Agent have the Power to Buy, Sell, or Exchange Stocks and Bonds? YesNo Buy, sell, and exchange stocks and bonds Commodities & Options Will the Agent have the Power to handle the Principal's Commodities and Options? Will the Agent have the Power to handle the Principal's Commodities and Options? YesNo 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; and establish, continue, modify, and terminate option accounts. Gifts Will the Agent have the Power to make Gifts? Will the Agent have the Power to make Gifts? YesNo In this section, a gift "for the benefit of" a person includes a gift 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. Section 529, as amended Business(es) Will the Agent have Power over the Principal's Business? (if any) Will the Agent have Power over the Principal's Business? (if any) YesNo The Agent will have power to operate, buy, or sell a business entity (or entities) that the Principal owns or operates. Insurance & Annuities Will the Agent have Power over any Insurance Policies or Annuities? Will the Agent have Power over any Insurance Policies or Annuities? YesNo To be able to pay the premium and have full control over the Insurance Policy and/or Annuity(ies). Estates, Trusts, etc. Will the Agent have power over the Principal's Estates, Trusts, and other Beneficial Interests? Will the Agent have power over the Principal's Estates, Trusts, and other Beneficial Interests? YesNo Claims & Litigation Will the Agent have Powers over Claims and Litigation? Will the Agent have Powers over Claims and Litigation? YesNo If the Principal has any claims or litigations that the Agent may continue to carry through with them. In other words if the Principal is involved with a lawsuit the Agent may be able to make decisions on the Principal's account. Family Obligations Will the Agent have Power to assist with the Principal's Family Obligations? Will the Agent have Power to assist with the Principal's Family Obligations? YesNo If there are children that are receiving financial assistance or child support. Or any family assistance, in general, to any relative. Special Instructions Will there be any Additional Powers or Special Instructions given to the Agent? Will there be any Additional Powers or Special Instructions given to the Agent? YesNo In addition to the Powers already given, the Agent has special instructions to: Commencement of Powers When will this Power of Attorney begin? When will this Power of Attorney begin? Immediately Upon Incapacitation Either immediately or upon incapacitation (incapacitation is described when a doctor claims a person cannot think for themselves due to a condition such as alzheimer's, coma, etc.) Reimbursement & Compensation Will the Agent be reimbursed for any expenses that occur during their time as Agent? Will the Agent be reimbursed for any expenses that occur during their time as Agent? Yes, the Agent shall be reimbursedNo, the Agent shall not be reimbursed Will the Agent be entitled to "reasonable compensation" for their duties? Will the Agent be entitled to "reasonable compensation" for their duties? YesNo Usually not required unless it is an attorney or other representative that is handling the duties of being an Agent. Signature Requirements This form must be signed in the presence of a Notary Public and at least One (1) Witness This form must be signed in the presence of a Notary Public and at least One (1) Witness I Agree Witness In accordance with Arizona State Law, the witness cannot be the agent, the agent's spouse, the agent's children or the notary public. Do you know the Witness's Name? Do you know the Witness's Name? YesNo Name of Witness First Last Next Save Save and finish later
