Fillable Printable Limited Power of Attorney - New Hampshire
Fillable Printable Limited Power of Attorney - New Hampshire
Limited Power of Attorney - New Hampshire
Page 1 of 9
PMFS 286 Ed. 01/2014
Instructions
Use this form to designate an Attorney-in-fact (known as Agent in Fact) on your mutual fund account(s). This Limited
Power of Attorney may not be used for trust, estate, custodian (including Uniform Gift to Minors/Uniform Transfers to
Minors accounts), employer-sponsored qualified retirement accounts, guardianship or conservator accounts.
Please follow these steps:
1. Complete all applicable sections of this agreement. Please print using blue or black ink.
2. The Account Owner(s) and Agent in Fact’s signature(s) must be notarized in Section 4.
3. Return your completed request to PMFS at the address below.
For assistance in completing this form, please contact the Prudential Mutual Fund Service Center at (800) 225-1852,
Monday through Friday between 8 a.m. and 6 p.m. Eastern time.
This form is not intended as legal advice. States other than New York, New Hampshire, Pennsylvania or Maine may
have requirements not specifically addressed in this form. Should you have any specific questions, please contact
your legal adviser.
1
Account
Owner
(Grantor)
Information
Mutual fund account number(s) (Grantor)
Provide complete account registration exactly as it appears on your account statement.
Name of account owner (first, middle initial, last name)
Social Security number (Grantor) (optional) Date of birth (mo., day, year)
Name of joint account owner, if any (first, middle initial, last name)
Social Security number (Grantor) (optional) Date of birth (mo., day, year)
Prudential Mutual Fund Services LLC (PMFS)
a Prudential Financial company
Limited Power of Attorney
For assistance:
Clients: (800) 225-1852
Pruco representatives: (800) 542-7117
Financial professionals: (888) 778-5471
Mailing
Instructions
Standard Prudential Mutual Fund Services LLC
mail to: PO Box 9658
Providence, RI 02940
Overnight Prudential Mutual Fund Services LLC
mail to: 4400 Computer Drive
Westborough, MA 01581
Important
Notes
• This Agreement will apply only with respect to the account numbers listed on this page.
• This Agreement is a limited power of attorney where the POA Agent’s powers will continue even after
the Account Owner’s future disability, incompetency or other event that may impact the relationship
between the Account Owner and the POA Agent, unless otherwise provided by applicable state law.
An Account Owner of sound mind may revoke this Agreement at any time in writing to PMFS.
• Each Account Owner who wishes to appoint the same POA Agent must sign this Agreement. Where
there are multiple Account Owners and each wish to designate a different POA Agent, then each
Account Owner must complete a separate Agreement identifying the desired individual.
Section 1: Account Owner (Grantor) Information
Section 2: Required State Notices to Principal (if applicable)
Section 3: Authorization
Section 4: Execution by Account Owner and Execution by POA Agent
Section 5: Required State Notices for POA Agents
ATTENTION
ACCOUNT
OWNER AND
POA AGENT
SHOULD
RETAIN A
COPY OF THIS
AGREEMENT
FOR THEIR
RECORDS.
(continued)
Page 2 of 9
PMFS 286 Ed. 01/2014
1
Account
Owner
(Grantor)
Information
(Continued)
The person named below has been assigned Limited Power of Attorney for:
¨ All joint owners
¨ Owner (Main account owner)
¨ Joint owner (Second account owner on a joint account)
¨ Other (Please specify.)
Name of Agent in Fact (first, middle initial, last name)
Address (You may use a PO box as a mailing address)
City State Zip code 4-digit ext.
Daytime telephone number (Agent in Fact) Extension Social Security number
2
Required
State
Notices to
Principal
If Account Owner is a resident of the State of New York, New Hampshire, Pennsylvania or Maine, please
read the following notice carefully and sign where indicated. If you are not a resident of these states,
please skip these sections and go to Section 3.
Your Power of Attorney is an important document. As the “principal,” you give the person whom you choose
(your “Agent”) authority to spend your money and sell or dispose of your property during your lifetime
without telling you. You do not lose your authority to act even though you have given your Agent similar
authority.
When your Agent exercises this authority, he or she must act according to any instructions you have
provided or, where there are no specific instructions, in your best interest. “Important Information for the
Agent” at the end of this document describes your Agent’s responsibilities.
Your Agent can act on your behalf only after signing the Power of Attorney before a notary public.
You can request information from your Agent at any time. If you are revoking a prior Power of Attorney , you
should provide written notice of the revocation to your prior Agent(s) and to any third parties who may have
acted upon it, including the financial institutions where your accounts are located.
You can revoke or terminate your Power of Attorney at any time for any reason as long as you are of sound
mind. If you are no longer of sound mind, a court can remove an Agent for acting improperly.
Your Agent cannot make health care decisions for you. You may execute a “Health Care Proxy” to do this.
The law governing Powers of Attorney is contained in the New York General Obligations Law, Article 5, Title
15. This law is available at a law library, or online through the New York State Senate or Assembly websites,
www.senate.state.ny.us or www.assembly.state.ny.us.
If there is anything about this document that you do not understand, you should ask a lawyer of your own
choosing to explain it to you.
Account Owner’s/Principal’s Name (please print)
X
Account Owner’s/Principal’s signature
month day year
NEW YORK: CAUTION TO PRINCIPAL
(continued)
Page 3 of 9
PMFS 286 Ed. 01/2014
2
Required
State
Notices to
Principal
(Continued)
NEW HAMPSHIRE - SIGNATURE REQUIRED
INFORMATION CONCERNING THE DURABLE POWER OF ATTORNEY
THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT YOU SHOULD KNOW
THESE IMPORTANT FACTS.
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 “Agent in Fact”) to make decisions, including, but not limited to,
decisions concerning your money, property, or both, and to use your money, property, or both on your
behalf. If this written Durable Power of Attorney does not limit the powers that you give to your Agent,
your Agent will have broad and sweeping powers to sell or otherwise dispose of your property, and to
spend your money without advance notice to you or approval by you. Under this document, your Agent will
continue to have these powers after you become incapacitated, and unless otherwise indicated your Agent
will have these powers before you become incapacitated.
You have the right to retain this Power and not to release this Power until you instruct your attorney or
any other person who may hold this Power of Attorney to so release it to your Agent pursuant to written
instructions. You have the right to revoke or take back this Durable Power of Attorney at any time, so long as
you are of sound mind. If there is anything about this Durable Power of Attorney that you do not understand,
you should seek professional advice.
Account Owner’s/Principal’s Name (please print)
X
Account Owner’s/Principal’s signature
month day year
PENNSYLVANIA - SIGNATURE REQUIRED
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 or otherwise dispose of any real or property without
advance notice to you or approval by you.
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.
Your Agent may exercise the powers given here throughout your lifetime, even after you become
incapacitated, unless you expressly limit the duration of these powers or you revoke these powers or a
court acting on your behalf terminates your Agent’s authority.
Your Agent must keep your funds separate from your Agent’s funds. A court can take away the powers of
your Agent if it finds your Agent not acting properly.
The powers and duties of an Agent under a power of attorney are explained more fully in 20 Pa.C.S. Ch. 56. 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.
I have read or had explained to me this notice and I understand its contents.
Account Owner’s/Principal’s Name (please print)
X
Account Owner’s/Principal’s signature
month day year
(continued)
Page 4 of 9
PMFS 286 Ed. 01/2014
2
Required
State
Notices to
Principal
(Continued)
MAINE - SIGNATURE REQUIRED
Notice to the Principal: As the “Principal” you are using this power of attorney to grant power to another
person (called the Agent) to make decisions about your property and to use your property on your behalf.
Under this power of attorney you give your Agent 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 power of attorney at any time as long as you are not incapacitated. If there is anything about
this power of attorney that you do not understand, you should ask a lawyer to explain it to you.
Account Owner’s/Principal’s Name (please print)
X
Account Owner’s/Principal’s signature
month day year
Page 5 of 9
PMFS 286 Ed. 01/2014
3
Authori-
zation
The undersigned (“Grantor”), by these present does make, constitute and appoint the above named (“Agent
in Fact”), the true and lawful Agent in Fact of the undersigned for and in the name, place and stead of
the undersigned, for the limited purpose of operating and conducting the account of the undersigned
with PMFS as said company now is or any time hereafter may be constituted, and at any offices of said
company, and in conjunction therewith to give and place any and all orders including (but not exclusively)
orders to purchase and/or sell and/or exchange and/or trade in, and/or assign, and/or transfer, and/or
authorize the registration of any of the mutual funds for which PMFS serves as transfer agent (the “Funds”)
for the withdrawal of funds and/or delivery of securities, and any and all other orders and/or instructions
that said Agent in Fact, in his or her unrestricted discretion, may deem desirable with reference to said
account of the undersigned with PMFS and with full power and authority to said Agent in Fact to receive,
accept and/or waive any notice and/or demand that said PMFS may give or issue with reference to or by
reason of the conduct of said account, giving and granting unto said Agent in Fact full power and authority
to do and perform all and every act and thing whatsoever requisite and necessary to be done in and
about the premises as fully to all intents and purposes as the undersigned could do if personally present,
including, but not limited to, instructing transfer agents, hereby ratifying and confirming any and all orders,
instructions and/or acts of said Agent in Fact heretofore or hereafter given or performed and executed or
complied with or relied on by said PMFS.
The undersigned hereby specifically authorizes and instructs said PMFS:
• That all payments of money instructed by said Agent in Fact to be paid to said Agent in Fact shall
be by check to the order of the undersigned and that all deliveries of any of the Funds and/or other
property instructed by said Agent in Fact to be delivered to said Agent in Fact , shall be registered
in the name of the undersigned, it being expressly provided that nothing contained in this clause is
intended to, nor shall it, restrict the authority of said Agent in Fact to give orders for the payment of
money against the delivery to you of securities or commodities or contracts, or for the delivery by you
of any of the Funds.
• That all notices, confirmations, statements and/or demands with reference to said account may be
served, mailed or delivered personally to or upon said Agent in Fact with the same force and effect as
though the same had been delivered to the undersigned; all such confirmations and statements may be
approved, in writing or otherwise, and/or executed by said Agent in Fact with the same force and effect
as though the same had been personally approved and/or executed personally by the undersigned.
• That check signing ability and right will be extended to and upon said Agent in Fact with the same force
and effect as though the same had been personally approved and/or executed by the undersigned.
PMFS is hereby fully authorized to act and rely on the authority and power vested pursuant hereto in the said
Agent in Fact. The undersigned confirms that said Agent in Fact is solely the Agent of the undersigned, and
that all acts and transactions of said Agent in Fact hereunder are solely for the account and responsibility
of the undersigned.
This Limited Power of Attorney shall not be affected by the subsequent disability or incompetence of
the undersigned.
This authority shall continue fully effective (and notwithstanding that the account of the undersigned may
have been closed and reopened at any time or from time to time), until said PMFS shall actually receive
written notice of cancellation bearing the signatures of the undersigned, and has had a reasonable period
of time to act on such notice. All orders executed and acts done by said PMFS in good faith after the death
of the undersigned or after the attempted revocation of this Limited Power of Attorney without actual notice
of such death or attempted revocation shall be and remain binding upon the undersigned and the legal
representatives, successors, and assignees of the undersigned. This Limited Power of Attorney shall be
construed under New Jersey law.
I hereby agree to indemnify and hold said PMFS and the Prudential Family of Mutual Funds harmless from
acting upon instructions, either oral or written, believed to have originated from said Agent in Fact and
from any and all acts of said Agent in Fact with respect to the shares held in the account with any of these
mutual funds.
This Limited Power of Attorney supersedes any prior power(s) of attorney provided to PMFS.
Page 6 of 9
PMFS 286 Ed. 01/2014
4
Execution
by Account
Owner
(Notarization
Required)
By signing below, I acknowledge that I have retained a copy of this Limited Power of Attorney, have
reviewed it, and agree to be bound by its terms. Further, if I am a resident of or am executing this Limited
Power of Attorney in the state of New York, New Hampshire, Pennsylvania or Maine, I acknowledge that I
have retained, read and understand the notice to Principal in Section 2.
Account Owner’s/Principal’s Name (please print) State of execution
X
Account Owner’s/Principal’s signature month day year
Sworn to and subscribed before me this day of , 20 .
Notary Public My Commission Expires
Affix Seal
Execution by
POA Agent
(Notarization
Required)
By signing below, I acknowledge that I have retained a copy of this Power of Attorney, have reviewed it,
and agree to be bound by its terms. Further, if I am a resident of or am executing this Power of Attorney in
the state of New York, New Hampshire, Pennsylvania or Maine, I acknowledge that I have retained, read
and understand the attached notice to POA Agent.
Agent in Fact’s Name (please print)
X
Agent in Fact’s signature month day year
Sworn to and subscribed before me this day of , 20 .
Notary Public My Commission Expires
Affix Seal
Witness
Section
(If required
by state law.)
On the date above written, , well known to us declared to us, and in our
Principal
presence, that this instrument is a Limited Power of Attorney, and then signed
Principal
Limited Power of Attorney in our presence, and at request we now sign this
Principal
Limited Power of Attorney as witnesses in each other’s presence. Further that
Principal
appeared to us to be of sound mind and lawful age, and under no undue influence.
X
Witness’s signature month day year
Address
X
Witness’s signature month day year
Address
(continued)
Page 7 of 9
PMFS 286 Ed. 01/2014
¨ Is required
¨ Is not required
Agent in Fact’s Name (please print)
X
Agent in Fact’s signature month day year
Certifying Physician (please print)
X
Certifying Physician’s signature
month day year
Affix Seal / Stamp
4
Certification of
Competency
(If required by
state law. )
I hereby certify that a certificate of competency, executed by a physician
Page 8 of 9
PMFS 286 Ed. 01/2014
5
Required
State
Notices
for POA
Agents
NEW YORK: IMPORTANT INFORMATION FOR THE AGENT
When you accept the authority granted under this Power of Attorney, a special legal relationship is created
between you and the principal. This relationship imposes on you legal responsibilities that continue until
you resign or the Power of Attorney is terminated or revoked. You must:
(1) act according to any instructions from the principal, or, where there are no instructions, in the
principal’s best interest;
(2) avoid conflicts that would impair your ability to act in the principal’s best interest;
(3) keep the principal’s property separate and distinct from any assets you own or control, unless
otherwise permitted by law;
(4) keep a record or all receipts, payments, and transactions conducted for the principal; and
(5) disclose your identity as an Agent whenever you act for the principal by writing or printing the
principal’s name and signing your own name as “Agent” in either of the following manners: (Principal’s
Name) by (Your Signature) as Agent, or (your signature) as Agent for (Principal’s Name).
You may not use the principal’s assets to benefit yourself or anyone else or make gifts to yourself or anyone
else unless the principal has specifically granted you that authority in this document, which is either a
Statutory Gifts Rider attached to a Statutory Short Form Power of Attorney or a Non-Statutory Power of
Attorney. If you have that authority, you must act according to any instructions of the principal or, where
there are no such instructions, in the principal’s best interest. You may resign by giving written notice to
the principal and to any co-Agent, successor Agent, monitor if one has been named in this document,
or the principal’s guardian if one has been appointed. If there is anything about this document or your
responsibilities that you do not understand, you should seek legal advice.
Liability of Agent: The meaning of the authority given to you is defined in New York’s General Obligations
Law, Article 5, Title 15. If it is found that you have violated the law or acted outside the authority granted to
you in the Power of Attorney, you may be liable under the law for your violation.
NEW HAMPSHIRE: NOTICE TO AGENT
INFORMATION CONCERNING THE DURABLE POWER OF ATTORNEY.
THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT YOU SHOULD KNOW
THESE IMPORTANT FACTS.
I, the Agent designated in Section 3 above, have read the attached power of attorney and am the person
identified as the Agent for the Principal. I hereby acknowledge that when I act as Agent or “Agent in Fact,”
I am given power under this Durable Power of Attorney to make decisions about money, property, or both
belonging to the Principal, and to spend the Principal’s money, property, or both 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 acting in the capacity of Agent, I am under a duty (called a “fiduciary duty”) to observe the standards
observed by a prudent person, which means the use of those powers that is reasonable in view of the
interests of the Principal and in view of the way in which a person of ordinary judgment would act in
carrying out that person’s own affairs. If the exercise of my acts is called into question, the burden will
be upon me to prove that I acted under the standards of a fiduciary. As the Agent, I am not entitled to use
the money or property for my own benefit or to make gifts to myself or others unless the Durable Power of
Attorney specifically gives me the authority to do so. As the Agent, my authority under this Durable Power of
Attorney will end when the Principal dies and I will not have authority to manage or dispose of any property
or administer the estate unless I am authorized to do so by a New Hampshire Probate Court. If I violate my
fiduciary duty under this Durable Power of Attorney, I may be liable for damages and may be subject to
criminal prosecution. If there is anything about this Durable Power of Attorney, or my duties under it, that I
do not understand, I understand that I should seek professional advice.
(continued)
Page 9 of 9
PMFS 286 Ed. 01/2014
5
Required
State
Notices
for POA
Agents
(Continued)
PENNSYLVANIA: NOTICE TO AGENT
I, the Agent designated in Section 3 above, have read the attached power of attorney and am the person
identified as the Agent for the principal. I hereby acknowledge that in the absence of a specific provision
to the contrary in the power of attorney or in 20 Pa.C.S. when I act as 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.
MAINE: NOTICE TO AGENT
As the “Agent” you are given power under this 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 power of attorney. This 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 power of attorney a special
legal relationship is created between you and the Principal. This relationship imposes upon you legal duties
that continue until you resign or the 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 power of attorney gives you such authority. If you violate your duty
under this 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 power of
attorney or your authority under this 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 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 power of attorney or your duties
under it that you do not understand you should ask a lawyer to explain it to you.
