Durable Power of Attorney

SUCCESSOR AGENT

If my Agent is unable or unwilling to serve for any reason, I name the following person as my Successor Agent:

Name:
Address:
Phone:
Email:

Financial and Property Powers

My Agent may:

Healthcare Powers

My Agent may:

Personal Care Powers

My Agent may make decisions regarding:

Business Powers

My Agent may:

SPECIAL INSTRUCTIONS

LIMITATIONS

My Agent MAY NOT do any of the following:

Successor Agent

I, _______________, have read the foregoing Power of Attorney and am the person identified as the Successor Agent. I hereby acknowledge that I accept the appointment as Successor Agent for the Principal.

Successor Agent Signature: ______________________________
Print Name: _______________
Date:

WITNESSES

I declare under penalty of perjury that the person who signed or acknowledged this document is personally known to me (or proved to me through satisfactory evidence) to be the Principal, that the Principal signed or acknowledged this Power of Attorney in my presence, that the Principal appears to be of sound mind and under no duress, fraud, or undue influence, that I am not the person appointed as Agent by this document, and that I am not a healthcare provider, an employee of a healthcare provider, the operator of a community care facility, or an employee of an operator of a community care facility.

Witness #1 Signature: ______________________________
Print Name:
Address:
Date:

Witness #2 Signature: ______________________________
Print Name:
Address:
Date:

NOTARY ACKNOWLEDGMENT

State of Select stateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
County of

On , before me, , personally appeared _______________, who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that they executed the same in their authorized capacity, and that by their signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of _______________ that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Notary Public Signature: ______________________________

(Seal)