Fillable Printable Limited Power of Attorney - International

Limited Power of Attorney - International

POWER OF ATTORNEY- INTERNATIONAL (3/2004) PAGE 1 OF 1

POWER OF ATTORNEY INTERNATIONAL - U.S. FORM

LIMITED POWER OF ATTORNEY

This Limited Power of Attorney is given on this ______________ day of ___________ , 20____ by

___________________________ of ___________________________________________________________,

(principal (address, city & state, country)

I appoint the following person:______________________________________________,

(name of attorney, agency)

of:___________________________________________

(address of attorney or agency)

_____________________________________________

(city and state)

to be my true and lawful attorney and give and grant said attorney full power and authority to do and perform on may behalf

all and every act and thing necessary for the specific and limited purpose only of obtaining support/maintenance for

____________________________________.

WITNESSED BY:

__________________________

______________________ _______________________

(Signature of Witness 1) (Signature of Witness 2) (principal’s signature)

__________________________ ______________________

(Print name of Witness 1)

(Print name of Witness 2)

__________________________ ______________________

(Address of Witness 1)

(Address of Witness 2)

CERTIFICATION/VERIFICATION REQUIREMENTS:

- Countries Other than the U.S.: This document must be executed in accordance with local law.

- For Use by US Tribunals/Agencies Only: This Power of Attorney must be notarized.

The foregoing instrument was acknowledged by me this ____ day of ________________, 20_____by:__________________________,

who is/are personally known by me or who has/have produced: ______________________________as identification and who

did not take an oath.

_____________________

__________________________ ______________________

County, State Notary Public Commission Expires