Fillable Printable Limited Power of Attorney Form - Louisiana

Limited Power of Attorney Form - Louisiana

LIMITED POWER OF ATTORNEY UNITED STATES OF AMERICA

BY: _______________________________ STATE OF LOUISIANA

Name of Principal

TO: _______________________________ PARISH OF__________________________

Name of Agent

BE IT KNOWN, THAT ON THIS ___________ day of __________________, 20______

BEFORE ME, ______________________________, a Notary Public, duly commissioned

and qualified in and for the Parish of ______________________, State of Louisiana, and in the

presence of the witnesses hereinafter named and undersigned:

PERSONALLY CAME AND APPEARED ___________________________________, a

Name of Principal

person of the full age of majority, whose mailing address is _____________________________,

Street or P. O. Box of Principal

________________________________, State of Louisiana, and whose Social Security Number is

City and Zip of Principal

_________________________, hereinafter referred to as “Principal,” who declared that Principal

SSN of Principal

has made and appointed, and by these presents Principal does make, name, nominate, ordain,

authorize, constitute and appoint in Principal’s stead, __________________________________, a

Name of Agent

person of the full age of majority, whose mailing address is ______________________________,

Street of P.O. Box of Agent

________________________________, State of Louisiana, and whose Social Security Number is

City and Zip of Agent

__________________________, hereinafter referred to as “Agent,” to be Principal’s true and

SSN of Agent

lawful Agent and attorney-in-fact, giving, and by these presents granting unto the Agent, full

power and authority for Principal and in Principal’s name and behalf to wit:

To receive the retirement check payable in the name of Principal from the Louisiana State

Employees Retirement System (LASERS) and deposit said check into the Principal’s bank

account or negotiate said check to pay the bills, and handle the affairs of the Principal herein, and

the Principal does give, grant and convey unto his or her Agent, full and complete authority to do

as the Agent may in his or her sole and uncontrolled discretion deems necessary and proper, to

sign any and all documents, changes of address forms, receipts or instruments that the Agent may

deem necessary and proper in connection with the handling of the receipt of the Retirement Check

and payment of the Principal’s bills and finally, to do and perform every act in connection with the

proposed transaction substantially as hereinabove set forth, to the same extent and in the

same manner as the Principal could do if personally present with Principal hereby ratifying,

approving and confirming each and every act done by the Agent.

THUS DONE AND PASSED before me, Notary, and the undersigned competent

witnesses ________________________________ and _____________________________ on the

_____ day of __________________, 20_____, at ____________________________, __________

WITNESSES:

_____________________________________ _____________________________________

Signature of Witness PRINCIPAL

_____________________________________ _____________________________________

Signature of Witness NOTARY PUBLIC ID No:

ACCEPTANCE

BEFORE ME, the undersigned Notary, personally came and appeared

________________________________ who stated that he or she does hereby accept the Limited

Name of Agent

Power of Attorney granted to him or her by _____________________________ on the ________,

Name of Principal

day of _________________________, ___________.

THUS DONE AND PASSED before me, Notary, and the undersigned competent

witnesses ___________________________________ and __________________________ on the

_______ day of ___________________, 20_____, at __________________________, _________

WITNESSES:

_____________________________________ _____________________________________

Signature of Witness AGENT Tax ID#:

_____________________________________ _____________________________________

Signature of Witness NOTARY PUBLIC ID No: