Date ____/____/______
I, do hereby [Legal Name]
A resident of [City][State]
Located at [Address]
[City], [State] [Zip Code]
Do Hereby Appoint [Legal Name]
A resident of [City][State]
Located at [Address]
[City], [State] [Zip Code]
As my attorney-in-fact to make the following specific decisions for me:
________________________________
________________________________
________________________________
________________________________
________________________________
This Special Power of Attorney is to start to be effective on ____/____/______, and shall remain effective until ____/____/______.
I do hereby grant my attorney-in-fact complete and full authority to act in any reasonable and necessary manner for the purpose of exercising the above mentioned powers. I also, ratify all the lawfully performed acts by my attorney-in-fact in exercising those powers.
I fully understand and agree that any third party who is given a copy of this Special Power of Attorney may act relying on it. I also, agree that revocation of this Special Power of Attorney is effective as to a third party only when they receive receipt of an actual notice by the third party. If due to reliance on the Special Power of Attorney, a third party suffers any loss, I agree to pay for any third party loss.
I sign my name to this Special Power of Attorney on:
__ Day of ____ Month ____ Year
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Signature
By accepting this appointment and acting under it, I the attorney-in-fact ("Agent") do hereby assume the legal responsibilities of an agent.
_______________________ Date_____
Signature of Attorney-in-Fact
WITNESS #1)
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WITNESS #2)
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