Fillable Printable Durable Power of Attorney - California
Fillable Printable Durable Power of Attorney - California
Durable Power of Attorney - California
DURABLE POWER OF ATTORNEY
(This Power of Attorney does not pertain to or provide any authority to your agent or
attorney-in-fact to deal with your retirement accounts for which MLPF&S is custodian.)
TO:
Merrill Lynch, Pierce, Fenner & Smith Incorporated (MLPF&S) and, if applicable, Merrill Lynch Life Agency Inc. (MLLA)
RE:
MLPF&S Account Number(s)
NOTE: When used in this document, the words "I", "me" or "my" refer to any client/principal, whether an individual or
an entity, that executes this Durable Power of Attorney.
(a) (PURCHASES AND SALES) to effect purchases and sales (including short sales), to subscribe for and to trade in all
types of securities and certain investments, including, but not limited to, stocks, bonds, options, limited partnership
interests, trust units, physical commodities and options thereon, on margin or otherwise, provided such transactions
are permissible under the terms of the account agreement governing the above-referenced MLPF&S account(s),
whether such securities or investments are in negotiable form, issued or unissued, or are traded on a foreign
exchange (including any foreign currency transactions necessary to effect the trade), to sell, assign, endorse and
transfer all types of securities and certain investments, including but not limited to stocks, bonds, options, certificates
of indebtedness, or certificates which evidence other securities of any nature, at any time standing in my name and
to execute any documents necessary to effectuate the foregoing; to receive statements o f transactions made for my
account(s); to approve and confirm the same, to receive any and all notices, calls for margin, or other demands with
reference to my account(s), to exercise employee stock options and to effect sales o f employer stock acquired
pursuant to such option exercising; and to direct payment to other broker-dealers, banks and other financial service
providers for purchases or trades made at such other firms, for my account or accounts at MLPF&S, whether presently
open or hereafter opened.
(b) (PROXY) to receive proxy soliciting materials, annual reports and other related materials and to vote proxies on
my behalf (or respond to requests for voting instructions) with respect to all securities and other assets held in my
account(s) at MLPF&S. If this power is initialed, the undersigned client/principal hereby represents the following to
MLPF&S: that the investment adviser designated above is registered under the Investment Advisers Act of 1940 and
that such adviser exercises investment discretion over my account(s) at MLPF&S pursuant to an advisory contract.
1 Code 1168-CR Rev. 1/15
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INITIAL ONLY THOSE POWERS YOU WANT YOUR INVESTMENT ADVISER TO EXERCISE
NOTE: You may revoke this power at any time by providing MLPF&S with written notice that all proxy soliciting materials,
annual reports and other related materials are to be sent directly to you and are no longer to be sent to your investment
adviser.
I hereby constitute and appoint_________________________________________(whose signature appears below), as my agent
and attorney-in-fact, with power and authority to act for me and on my behalf in connection with my account(s) with
MLPF&S and annuity contracts and life insurance policy(ies) owned by me and linked to my account(s) at MLPF&S or for which I
am entitled to benefits thereunder, however designated, and whether presently open or hereafter opened, specifically
conferring upon my agent and attorney-in-fact those powers which I have designated below by initialing the corresponding
space provided to the left of each power that I wish to confer.
I agree that this Durable Power of Attorney shall be applied to the MLPF&S accounts that I have listed above and annuity contract(s)
and life insurance policy(ies) owned by me and linked to my account(s) at MLPF&S and that it may also be applied to any identically
titled account(s) that I establish at MLPF&S and/or identically titled annuity contract(s) and life insurance policy(ies) that I own and are
linked to my accounts at MLPF&S in the future, unless I notify you otherwise in writing.
PART I:
If the agent and attorney-in-fact is a registered Investment Adviser, choose from the powers listed
below in this Part I:
Initial here (Do not make a mark):
In connection with the above direction, I agree that the investment adviser's fees shall be paid first (a) from free
credit balances, if any, in my account(s); and second, (b) from the liquidation or withdrawal (which the client/
principal hereby authorizes by his/her signature below) by MLPF&S of my shares of any money market funds or
balances in my account(s) at MLPF&S. I further agree that MLPF&S shall be under no other duty or obligation to pay
the investment adviser's fee, that I shall be solely responsible for verifying the accuracy or calculation of fees
submitted for such payment, and that the investment adviser named above has been directed to submit an invoice
or statement for each payment of fees to me and to MLPF&S, stating the client's name, which MLPF&S account
number the fee is to be paid from, and the amount to be paid. This fee payment authorization shall remain in full force and
effect until terminated by one of the parties hereto, and such termination shall be effective upon receipt of written
notice by MLPF&S. MLPF&S may terminate this fee payment arrangement at any time.
NOTE: If this paragraph (c) (FEES) has been initialed by the client/principal, the investment adviser/agent, by signing below,
makes the following representations to MLPF&S: That I/we have entered into an agreement with the client/principal for
investment advisory services which authorizes me/us to receive direct payment from the client's/ principal's account(s) at
MLPF&S upon presentation of my/our invoice or statement to MLPF&S. I/We acknowledge and agree to all of the foregoing
terms and conditions of my/our client's above authorization to MLPF&S, and I/we agree to hold MLPF&S harmless for
amounts paid to me/us upon receipt of my/our invoice or statement.
(a) (PURCHASES AND SALES) to effect purchases and sales (including short sales), to subscribe for and to trade in all
types of securities and certain investments, including, but not limited to, stocks, bonds, options, limited partnership
interests, trust units, physical commodities and options thereon, on margin or otherwise, provided such transactions
are permissible under the terms of the account agreement governing the above-referenced MLPF&S account(s),
whether such securities or investments are in negotiable form, issued or unissued, or are traded on a foreign
exchange (including any foreign currency transactions necessary to effect the trade), and to sell, assign, endorse and
transfer all types of securities and certain investments, including but not limited to stocks, bonds, options,
certificates of indebtedness, or certificates which evidence other securities of any nature, at any time standing in my
name and to execute any documents necessary to effectuate the foregoing; to receive statements of transactions
made for my account(s); to approve and confirm the same, to receive any and all notices, calls for margin, or other
demands with reference to my account(s), to exercise employee stock options and to effect sales o f employer stock
acquired pursuant to such option exercising; and to direct payment to other broker-dealers, banks and other
financial service providers for purchases or trades made at such other firms, for my account or accounts at MLPF&S,
whether presently open or hereafter opened.
(b) (WITHDRAWAL OF FUNDS AND SECURITIES) to instruct MLPF&S to make payment of moneys and/or securities
from my account(s) at MLPF&S, and to receive and direct payments therefrom payable to me or for my benefit.
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(c) (FEES) MLPF&S is hereby authorized, upon receipt of invoices or statements from the investment adviser named
above, to pay such amounts in connection with the above account(s) to:
Name of Investment Adviser ___________________________________________________________________________
Address of Investment Adviser __________________________________________________________________________
(d) (DURABILITY) APPLICABLE ONLY TO U.S. RESIDENT CLIENTS (INCLUDING U.S. RESIDENT ALIENS). (INITIAL ONLY
IF YOU WANT YOUR AGENT TO CONTINUE TO ACT ON YOUR ACCOUNT(S) IF YOU BECOME MENTALLY
INCAPACITATED.) This Durable Power of Attorney shall not be affected by the subsequent disability, incompetence
or incapacity of the principal or by any lapse of time. (Maine residents see statement below.) Also, see below for any
additional execution requirements for durability. Not eligible for trust accounts.
NOTE: *ADDITIONAL EXECUTION REQUIREMENTS FOR DURABLE POWERS OF ATTORNEY EXIST FOR CLIENTS RESIDING IN
CERTAIN STATES. THESE ADDITIONAL REQUIREMENTS ARE SET FORTH IN DETAIL ON PAGE 8 OF THIS POWER OF
ATTORNEY. IF THE CLIENT'S STATE OF RESIDENCE CHANGES AFTER THE CLIENT HAS EXECUTED THIS DURABLE POWER OF
ATTORNEY, THE CLIENT SHOULD CONSULT WITH HIS OR HER OWN LEGAL COUNSEL TO DETERMINE IF THIS DURABLE
POWER OF ATTORNEY SHOULD BE RE-EXECUTED.
PART II:
If the agent and attorney-in-fact is not a registered Investment Adviser, choose from the powers
listed below in this Part II:
INITIAL
ONLY THOSE POWERS YOU WANT YOUR AGENT AND ATTORNEY-IN-FACT TO EXERCISE
Initial here (Do not make a mark);
(d) (TRANSFERS; GIFTING AUTHORITY - TO AGENT) to make transfers and gifts of any amount of money, stocks, bonds,
options, limited partnership interests, trust units, or other securities, or any other property or investments, from my
account(s) at MLPF&S or of annuity contract(s) or life insurance policy(ies) owned by me and linked to my account(s)
at MLPF&S, or of loan, withdrawal or surrender values of those annuity contract(s) or life insurance policy(ies), on my behalf
to my agent and attorney-in-fact, provided however, that such gifts are for my agent and attorney-in-fact's health,
education, support or maintenance (such determination shall not be made by MLPF&S);
(e) (CHECK WRITING) to make and draw checks;
(f) (TAX DOCUMENTS) to execute tax forms related to my account(s) at MLPF&S, including, but not limited to, forms
which certify my taxpayer identification number, backup withholding status, foreign status and/or tax following IRS
form that is applicable to me and that I have initialed below, I understand that I must only initial next to one residency.
Specifically, my agent and attorney-in-fact is authorized to prepare, execute, and present on my behalf the form:
(g) (LIFE INSURANCE POLICIES) to exercise all available ownership rights on policy(ies) owned by me and linked to my
account(s) at MLPF&S, including, but not limited to, the right to cancel or exchange the policy(ies) and receive the net cash
surrender value or to choose one or more income plans on canceling the policy(ies), to apply for and receive policy loans, to
collaterally assign the policy(ies), to change the allocation between and among the available investment options of the
company in which the policy(ies) are funded, to make or change the beneficiary and ownership designations of the policy
(ies) and to make inquiries and receive information as to the cash value and death benefit of the policy(ies). To accept,
reject, disclaim, receive, receipt for, sell, assign, release, pledge, exchange or consent to a reduction in or
modification of any share in or payment from a policy for which I am named a beneficiary that is linked to or held in any
account at MLPF&S.
(h) (ANNUITIES) to exercise all available ownership rights under contract(s) owned by me and linked to my account(s) at
MLPF&S, including but not limited to, the right to select or change an annuitant(s), the annuity date, the annuity option or
the allocation between and among the available investment options, to cancel or exchange the contract(s) and receive
beneficiary designations or ownership designations of the contract(s), to exercise all available benefits and or riders, and the
net value, to make withdrawals from the contract(s), to collaterally assign the contract(s), to make or change the to
make inquiries and receive information as to the cash value and death benefit of the contract(s). To accept, reject, disclaim,
receive, receipt for, sell, assign, release, pledge, exchange or consent to a reduction in or modification of any share in or
payment from a contract for which I am named a beneficiary that is linked to or held in any account at MLPF&S.
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Note: I understand that if I do not initial next to the one appropriate tax form listed above, my agent and attorney-
in-fact will not be able to execute such form for me and if I am unable to do so myself, I may be subject to backup
withholding.
_________ Form W-9
_________ Form W-8BEN
_________ Form W-8IMY
_________ Form W-8ECI
_________ Form W-8EXP
INITIAL ONLY ONE:
(c) (TRANSFERS; GIFTING AUTHORITY - TO 3rd PARTIES) to make transfers and gifts of any amount of money, stocks, bonds,
options, limited partnership interests, trust units, or other securities, or any other property or investments, from my
account(s) at MLPF&S or of annuity contract(s) or life insurance policy(ies) owned by me and linked to my account(s) at
MLPF&S, or of loan, withdrawal or surrender values of those annuity contract(s) or life insurance policy(ies) on my behalf to
any third party, including, but not limited to, individuals, entities, trusts, or charitable organizations, provided however, that
any such gift shall not discharge an obligation of support of my agent and attorney-in-fact (such determination
shall not be made by MLPF&S);
NOTE: If you have initialed paragraph (c) or (d) in this Part II of the Power of Attorney, you have given your agent and
attorney-in-fact the authority to give away your assets to third parties or to your agent and attorney-in-fact. If you do
not want your agent and attorney-in-fact to have this authority, do not initial paragraph (c) or (d) in this Part II of the
Power of Attorney. If there is anything about this Power of Attorney that you do not understand, you should consult
your own attorney.
(i) (DURABILITY) APPLICABLE ONLY TO U.S. RESIDENT CLIENTS (INCLUDING U.S. RESIDENT ALIENS). (INITIAL ONLY IF
YOU WANT YOUR AGENT TO CONTINUE TO ACT ON YOUR ACCOUNT(S) IF YOU BECOME MENTALLY
INCAPACITATED.) This Durable Power of Attorney shall not be affected by the subsequent disability,
incompetence or incapacity of the principal or by any lapse of time. (Maine residents see statement below.) Also, see
below for additional execution requirements for durability. Not eligible for trust accounts.
4 Code 1168-CR Rev. 1/15
MLPF&S, MLLA and any insurance company issuing annuity contracts and life insurance policies owned by me and linked to my
accounts at MLPF&S accordingly are authorized and empowered to follow the instructions of my said agent and attorney-in-fact
with respect to the powers set forth and initialed above with respect to my account(s) at MLPF&S and annuity contract(s) and life
insurance policy(ies) owned by me and linked to my account(s) at MLPF&S; provided such instructions and transactions are
permissible under the terms of my applicable account agreement(s) with MLPF&S and those annuity contract(s) and life
insurance policy(ies), and I hereby ratify and confirm any and all transactions, trades, or dealings effected in and for my MLPF&S
account(s) and with regard to annuity contract(s) and life insurance policy(ies) owned by me and linked to my account(s) at
MLPF&S by my agent and attorney-in-fact, and agree to indemnify MLPF&S and MLLA, their affiliates, officers, agents and
employees of MLPF&S and MLLA and their affiliates and hold them free and harmless from any loss, liability, or damage by reason
of any such transaction, trade or dealing, or by reason of any other matter or thing done by MLPF&S and MLLA, their affiliates,
officers, agents and employees of MLPF&S and MLLA and their affiliates in and for my account(s) at MLPF&S and with regard to
annuity contract(s) and life insurance policy(ies) owned by me and linked to my account(s) at MLPF&S pursuant to instructions
received from my agent and attorney-in-fact.
This power of attorney, authorization and indemnity shall not be affected by lapse of time. It shall continue in full force and effect,
and MLPF&S and MLLA, and their successors and assigns shall be indemnified in relying thereon, until MLPF&S and MLLA
shall receive written notice of revocation thereof, signed by me; or in the event of the termination thereof by my death,
or my mental incapacity (if I have not elected to make this Power of Attorney durable), until MLPF&S and MLLA shall have
received actual notice thereof, and such revocation or termination shall in no way affect the validity of this Power of Attorney
and my liability under the indemnity herein contained, with reference to any transaction initiated by my agent and attorney-in-
fact, prior to the actual receipt by MLPF&S and MLLA of notice of such revocation or termination, as above provided.
To induce any transfer agent or other third party to act, I hereby agree that any transfer agent or other third party receiving a duly
executed copy or facsimile of this Power of Attorney may act upon it, and that revocation or termination hereof shall or
termination shall have been received by such transfer agent or other third party, and I for myself and for my heirs, be
ineffective as to such transfer agent or other third party, unless and until actual notice or knowledge of such revocation
executors, legal representatives and assigns, hereby agree to indemnify and hold harmless any such transfer agent or other
third party from and against any and all claims that may arise against such transfer agent or other third party by reason of
such transfer agent or third party having relied on this Power of Attorney.
I have read carefully the provisions of this Power of Attorney and understand that it authorizes my agent and attorney-in-fact,
herein named, to exercise all rights and powers set forth and initialed above with respect to my account(s) with MLPF&S and
annuity contract(s) and life insurance policy(ies) owned by me and linked to my account(s) at MLPF&S, and I understand that
anything my agent may do in the exercise of such rights and powers is fully binding upon me.
I understand that MLPF&S and MLLA have not provided any advice that this Power of Attorney satisfies the requirements
under the laws of the state in which it is to be effective, and if there is anything about this Power of Attorney that I do not
understand, I should consult with my attorney for an explanation.
8510029323
I have inquired as to whether or not my agent and attorney-in-fact is registered (or is otherwise exempt from registration)
with the Securities and Exchange Commission under the Investment Advisers Act of 1940 and with the appropriate state
experience, qualifications and reputation of my agent and attorney-in-fact and am satisfied with the experience, authority
of my state of residence, where such registration would be required. In addition, I have investigated the business
qualifications and reputation of my agent and attorney-in-fact.
This power of attorney, authorization and indemnity is in addition to (and in no way limits or restricts) any and all rights which
MLPF&S and MLLA may have under any other agreement or agreements between MLPF&S and MLLA and me, and shall inure and
continue in favor of MLPF&S and MLLA, their successors (by merger, consolidation or otherwise) and assigns.
If I have appointed two or more agents and attorneys-in-fact, I hereby authorize them to act alone and without the consent of the
other agent or agents, with respect to the powers granted above. In addition, I hereby authorize MLPF&S to restrict my account(s)
from further activity in the event the agents enter conflicting or inconsistent instructions. I also hereby authorize any insurance
company issuing my annuity contract(s) and life insurance policy(ies) to restrict my contract(s) and life insurance policy(ies) from
further activity in the event the agents enter conflicting or inconsistent instructions. I understand that my account(s), annuity
contract(s), and life insurance policy(ies) may remain restricted until written instructions are received from me, the
principal, or until joint written instructions are submitted by all of my agents.
NOTE: *ADDITIONAL EXECUTION REQUIREMENTS FOR DURABLE POWERS OF ATTORNEY EXIST FOR CLIENTS RESIDING IN
CERTAIN STATES. THESE ADDITIONAL EXECUTION REQUIREMENTS ARE SET FORTH IN DETAIL ON PAGE 8 OF THIS POWER
OF ATTORNEY. IF THE CLIENT'S STATE OF RESIDENCY CHANGES AFTER THE CLIENT HAS EXECUTED THIS DURABLE POWER
OF ATTORNEY, THE CLIENT SHOULD CONSULT WITH HIS OR HER OWN LEGAL COUNSEL TO DETERMINE IF THIS DURABLE
POWER OF ATTORNEY SHOULD BE RE-EXECUTED.
5 Code 1168-CR Rev. 1/15
WITNESSES (one witness is required per client signature, see
page 8 to determine if an additional witness or notarization
is necessary):
__________________________________________________
Signature of Witness 1
__________________________________________________
Printed Name of Witness 1
__________________________________________________
Signature of Witness 2
__________________________________________________
Printed Name of Witness 2
WITNESSES (one witness is required per client signature, see
page 8 to determine if an additional witness or notarization
is necessary):
__________________________________________________
Signature of Witness 1
__________________________________________________
Printed Name of Witness 1
__________________________________________________
Signature of Witness 2
__________________________________________________
Printed Name of Witness 2
This is an important legal document. Before executing this Power of Attorney you should know these
important facts:
NOTE:
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AGENT INFORMATION AND SIGNATURE
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I hereby represent that I am familiar with and have reviewed the investment goals, guidelines and objectives of the
client; and that I will invest consistently with his or her stated goals, guidelines and objectives.
__________________________________________ ______________________________ ____________________
Signature of Agent Agent's SSN/TIN Agent’s Date of Birth
______________________________________ ________________________________________________
Name of Agent's Employer (if any) Agent's Occupation
______________________________________ ________________________________________________
Agent's MLPF&S Account Number(s) (if any) Agent's Address
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1. Depending on the powers you have authorized for your agent and attorney-in-fact, this document may provide
the person you designated as your agent and attorney-in-fact with broad powers including, but not limited to,
the management, transfer, withdrawal, gifting or sale of the assets in your MLPF&S account and of your annuity
contracts and life insurance policy(ies) owned by you and linked to your account(s) at MLPF&S.
2. If you have selected durability (paragraph (d) under Part I or paragraph (i) under Part II), your agent's and
attorney-in-fact's authority will continue notwithstanding your subsequent mental disability or incapacity.
3. You have the right to revoke or terminate this Power of Attorney at any time and any such revocation or
termination shall be effective upon receipt of written notice by MLPF&S and MLLA.
4. If there is anything about this Power of Attorney you do not understand, you should consult with your own
attorney.
_________________________________________
Signature of Client/Principal
_________________________________________
Printed Name of Client/Principal
_________________________________________
Title (e.g., Trustee, President, etc.)
MUST be completed for fiduciary accounts (if not
completed, document will be rejected).
*Note for accounts with more than one Client/
Principal please ensure all parties have signed.
_________________________________________
Signature of Client/Principal
_________________________________________
Printed Name of Client/Principal
__________________________________________
Title (e.g., Trustee, President, etc.)
MUST be completed for fiduciary accounts (if not
completed, document will be rejected).
*Note for accounts with more than one Client/
Principal please ensure all parties have signed.
Dated this _________ day of___________________________________ , 20_______ .
8510029323
6 Code 1168-CR Rev. 1/15
CERTIFICATE OF ACKNOWLEDGEMENT OF NOTARY PUBLIC
Notary Acknowledgement:
State of___________________________
County of__________________________
The foregoing instrument was acknowledged before me, a Notary Public, this _____________
day of _____________________, 20______ by _______________________________, the person whose
name is subscribed to the within instrument and acknowledged to me that he/she executed the same in
his/her authorized capacity, and that by his/her signature on the instrument the person or entity upon
which the person acted, executed the instrument.
PLEASE CHECK ONE OF THE FOLLOWING (REQUIRED):
Personally known
Or
Produced identification Type of Identification Produced_________________________________
WITNESS my hand and official seal (Seal)
______________________________________________________
Signature of Notary Public
______________________________________________________
Print Name of Notary Public
My commission expires:___________________________________
PLEASE NOTE THAT ALL FIELDS, INCLUDING THE BOXES BELOW, MUST BE COMPLETED BY THE NOTARY
(OR THE DOCUMENT WILL BE REJECTED).
THIS ACKNOWLEDGEMENT FORM MAY NOT BE USED BY CALIFORNIA NOTARIES.
CALIFORNIA NOTARIES ARE TO USE THE ATTACHED CALIFORNIA ACKNOWLEDGEMENT FORM OR
THE NOTARIAL ACKNOWLEDGMENT FORM AVAILABLE ON THE CALIFORNIA SECRETARY OF
STATE WEBSITE.
8510029323
A notary public or other officer completing this certificate
verifies only the identity of the individual who signed the
document to which this certificate is attached, and not
the truthfulness, accuracy, or validity of that document.
ACKNOWLEDGEMENT
State of California
County of__________________________)
On _________________________ before me, _________________________________________________,
(Insert name and title of the officer)
personally appeared ______________________________________________________________________,
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/
her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s),
or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal
______________________________________________________ (Seal)
Signature
7 Code 1168-CR Rev. 1/15
CALIFORNIA NOTARIES MUST USE THIS ACKNOWLEDGEMENT FORM OR THE NOTORIAL
ACKNOWLEDGEMENT FORM AVAILABLE ON THE CALIFORNIA SECRETARY OF STATE WEBSITE.
8510029323
8 Code 1168-CR Rev. 1/15
ALABAMA: All Powers of Attorney must be notarized.
ARIZONA: This Power of Attorney form may not be used by Arizona residents. Use the code 1298-CR, Arizona Durable Power of
Attorney.
ARKANSAS: All Powers of Attorney must be notarized.
CALIFORNIA: This Power of Attorney form may not be used by California residents. Use the code 0890-CR, California Durable
Power of Attorney. For non-California residents having this form notarized in the state of California, use acknowledgement on
page 7.
COLORADO: All Powers of Attorney must be notarized.
CONNECTICUT: This Power of Attorney must be witnessed by two individuals.
DELAWARE: All Powers of Attorney must be witnessed by at least one witness and be notarized. The additional disclosures on
pages 9 and 10 must be read and executed by the Principal and Agent.
FLORIDA: All Powers of Attorney must be witnessed by two individuals and must also be notarized.
HAWAII: All Powers of Attorney must be notarized.
IDAHO: All Powers of Attorney must be notarized.
ILLINOIS: All Powers of Attorney must be witnessed by at least one witness and be notarized.
INDIANA: All Powers of Attorney must be notarized.
IOWA: All Powers of Attorney must be notarized (for all Powers of Attorney executed on or after 7/1/2014).
KANSAS: To be durable, this Power of Attorney must be notarized.
MAINE: All Powers of Attorney must be notarized.
MARYLAND: All Powers of Attorney must be witnessed by two adult individuals. Powers of Attorney must also be notarized. The
notary may serve as one of the two adult witnesses.
MICHIGAN: All Powers of Attorney must be either 1) witnessed by two individuals OR 2) notarized.
The additional disclosure on page 12 must be read and executed by the Agent.
MISSOURI: To be durable, this Power of Attorney must be notarized.
MONTANA: All Powers of Attorney must be notarized.
NEBRASKA: All Powers of Attorney must be notarized.
NEVADA: All Powers of Attorney must be notarized.
NEW HAMPSHIRE: To be durable, this Power of Attorney must be notarized and the additional disclosures on pages 13 and 14
must be read and executed by the Principal and Agent.
NEW JERSEY: All Powers of Attorney must be notarized.
NEW MEXICO: All Powers of Attorney must be notarized.
NEW YORK: This Power of Attorney form may not be used by New York residents. Use the code 1168NY-CR, New York Durable
Power of Attorney.
NORTH CAROLINA: This Power of Attorney form may not be used by North Carolina residents. Use the code 1168NC-CR, North
Carolina Durable Power of Attorney.
OKLAHOMA: All Powers of Attorney must be witnessed by two individuals. Powers of Attorney must also be notarized.
PENNSYLVANIA: This Power of Attorney may not be used by Pennsylvania residents. Use the code 0484-CR, Pennsylvania Durable
Power of Attorney.
SOUTH CAROLINA: This Power of Attorney may not be used by South Carolina residents. Use the code 1168SC-CR, South Carolina
Durable Power of Attorney.
TEXAS: To be durable, this Power of Attorney must be notarized.
US VIRGIN ISLANDS: All Powers of Attorney must be notarized.
VERMONT: This Power of Attorney may not be used by Vermont residents. Use the code 1168VT-CR, Vermont Durable Power of
Attorney.
VIRGINIA: All Powers of Attorney must be notarized.
WEST VIRGINIA: All Powers of Attorney must be notarized.
WISCONSIN: All Powers of Attorney must be notarized.
STATE SPECIFIC EXECUTION REQUIREMENTS IF THE CLIENT/PRINCIPAL IS A RESIDENT OF:
9 Code 1168-CR Rev. 1/15
8510029323
Date
Principal
______________________________
___________________________________________________
I have read or had explained to me this notice and I understand its contents.
If there is anything about this form that you do not understand, you should ask a lawyer of your own
choosing to explain it to you.
The powers and duties of an Agent under a durable power of attorney are explained more fully in Delaware
Code, Title 12, Chapter 49A, Section 49A-114 and Sections 49A-201 through 49A-217.
A court can take away the powers of your Agent if it finds your Agent is not acting properly.
Your Agent must keep your funds and other property separate from your Agent's funds and other property.
This power of attorney does not impose a duty on your Agent to exercise granted powers, but when powers
are exercised, your Agent must use due care to act for your benefit and in accordance with this power of
attorney.
Unless you specify otherwise, your Agent's authority will continue even if you become incapacitated, or until
you die or revoke the power of attorney, or until your Agent resigns or is unable to act for you. You should
select someone you trust to serve as your Agent.
This power of attorney does not authorize the Agent to make health-care decisions for you.
Notice to Principal: As the person signing this durable power of attorney, you are the Principal. The
purpose of this power of attorney is to give the person you designate (your "Agent") broad powers to handle
your property, which may include powers to sell, dispose of, or encumber any real or personal property
without advance notice to you or approval by you.
TO BE EXECUTED BY THE PRINCIPAL AS PART OF A DELAWARE
DURABLE POWER OF ATTORNEY
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Date
Agent
____________________________
___________________________________________
I shall exercise the powers for the benefit of the Principal.
I shall keep the assets of the Principal separate from my assets.
I shall exercise reasonable caution and prudence.
I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the Principal.
I shall, to the extent reasonably practicable under the circumstances, keep in regular contact with the
Principal and communicate with the Principal.
provision to the contrary in the durable power of attorney, when I act as Agent:
of my knowledge this power has not been revoked. I hereby acknowledge that, in the absence of a specific
attorney and I am the person identified as the Agent or identified as the Agent for the Principal. To the best
name of agent
I _____________________________, have read the attached durable power of
AGENTS CERTIFICATION:
TO BE EXECUTED BY THE AGENT AS PART OF A DELAWARE
DURABLE POWER OF ATTORNEY
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Notice to the Agent: As the "Agent" or "Attorney-in-fact", you are given power under this Durable Power of Attorney
to make decisions about the property belonging to the Principal and to dispose of the Principal's property on the
Principal's behalf in accordance with the terms of this Durable Power of Attorney. This Durable Power of Attorney is
valid only if the Principal is of sound mind when the Principal signs it. When you accept the authority granted under
this Durable Power of Attorney a special legal relationship is created between you and the Principal. This relationship
imposes on you legal duties that continue until you resign or the Durable Power of Attorney is terminated or revoked. The
duties are more fully explained in the Maine Uniform Power of Attorney Act, Maine Revised Statutes, Title 18-A, Article 5,
Part 9 and Title 18-B, sections 802 to 807 and Title 18-B, chapter 9. As the Agent, you are generally not entitled to
use the Principal's property for your own benefit or to make gifts to yourself or others unless the Durable Power of Attorney
gives you such authority. If you violate your duty under this Durable Power of Attorney, you may be liable for damages
and may be subject to criminal prosecution. You must stop acting on behalf of the Principal if you learn of any event that
terminates this Durable Power of Attorney or your authority under this Durable Power of Attorney. Events of
termination are more fully explained in the Maine Uniform Power of Attorney Act and include, but are not limited to,
revocation of your authority or of the Durable Power of Attorney by the Principal, the death of the Principal or the
commencement of divorce proceedings between you and the Principal. If there is anything about this Durable Power of
Attorney or your duties under it that you do not understand, you should ask a lawyer to explain it to you.
Notice to the Principal: As the "Principal", you are using this Durable Power of Attorney to grant power to another
person (called the "Agent" or "Attorney-in-fact") to make decisions about your property and to use your property on
your behalf. If this written Durable Power of Attorney does not limit the powers that you give your Agent, your
Agent will have broad and sweeping powers to sell or otherwise dispose of your property without notice to you.
Under this document, your Agent will continue to have these powers after you become incapacitated. The powers that
you give your Agent are explained more fully in the Maine Uniform Power of Attorney Act, Maine Revised Statutes, Title
18-A, Article 5, Part 9. You have the right to revoke this Durable Power of Attorney at any time as long as you are not
incapacitated. If there is anything about this Durable Power of Attorney that you do not understand, you should ask a
lawyer to explain it to you.
FOR ALL CLIENTS WHO ARE MAINE RESIDENTS, PLEASE READ THE
FOLLOWING STATEMENTS WHICH ARE REQUIRED BY MAINE REVISED STATUTES,
TITLE 18-A § 5-509(B)
NOTE TO ALL MAINE RESIDENTS: Maine law requires that this Durable Power of Attorney contain the
following statements; however, certain sections of these statements may be inapplicable to this Durable
Power of Attorney. If there is anything about this Durable Power of Attorney that you do not understand, you
should consult with your own attorney.
