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 County of Principal County 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 Principal's Contact Principal's Telephone Number Principal's E-Mail Address 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 Mailing Address Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Agent's Contact Agent's Telephone Number Agent's E-Mail 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 2nd Agent Contact 2nd Agent's Email Address 2nd Agent's Telephone Number Agent's Powers Will the Agent have Unrestricted just Specific financial powers? Will the Agent have Unrestricted just Specific financial powers? UnrestrictedSpecific Enter the Agent's Powers (check all that apply) Enter the Agent's Powers (check all that apply) Real PropertyTangible Personal PropertyStocks and BondsCommodities and OptionsBanks and Other Financial InstitutionsOperation of Entity or BusinessInsurance and AnnuitiesEstates, Trusts, and Other Beneficial InterestsClaims and LitigationPersonal and Family MaintenanceBenefits From Governmental Programs or Civil or Military ServiceRetirement PlansTaxes Initial The Principal must Initial the Financial Powers selected after the form has been printed The Principal must Initial the Financial Powers selected after the form has been printed I Understand Additional Powers In addition to the powers selected previously, will the agent have any additional powers? (check all that apply) In addition to the powers selected previously, will the agent have any additional powers? (check all that apply) Create, Amend, or Revoke TrustsMake GiftsCreate or Change Rights of SurvivorshipCreate or Change a Beneficiary DesignationAuthorize Another Person to Have Power in this Power of AttorneyWaive the Principal's Right to be a Beneficiary Under a Retirement PlanAccess the Content of Electronic CommunicationsExercise Fiduciary PowersDisclaim or Refuse an Interest in Property Initial The Principal must Initial any Additional Powers selected after the form has been printed The Principal must Initial any Additional Powers selected after the form has been printed I Understand 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: Conservator Would you like the Agent to also be the Conservator? Would you like the Agent to also be the Conservator? YesNo This is to inform a court of the agent's appointment in this power of attorney rather than have a court appointed conservator Notary and 1 Witness The Principal understands that this Power of Attorney Form must be signed in the presence of a Notary Public and 1 Witness The Principal understands that this Power of Attorney Form must be signed in the presence of a Notary Public and 1 Witness Yes A notary public can be found at any bank branch or credit union. Next Save Save and finish later
