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Fillable Printable Power of Attorney Form - Ohio

Fillable Printable Power of Attorney Form - Ohio

Power of Attorney Form - Ohio

Power of Attorney Form - Ohio

Power of Attorney
[This form is from Ohio Revised Code section 1337.18. The powers granted by this document
are broad and sweeping. They are explained in Ohio Revised Code section 1337.20. If you
have any questions about these powers, obtain legal advice. You can use any different form of
power of attorney you may desire. This document does not authorize anyone to make health-
care decisions for you. You can revoke this power of attorney at any time.]
Principal (Person Granting the Power):
Name: ______________________________________________________________________
Address: ____________________________________________________________________
Telephone: ______________ ____________________________________________________
1. Notice to Principal.
As the principal, you are using this document to give authority to another person, known
as your agent or attorney-in-fact, to make decisions regarding your money and property. Your
agent will have the powers that you indicate below to make decisions about your money and
property without advance notice to you or approval by you.
Unless expressly authorized in the power of attorney, a power of attorney does not grant
authority to an agent to do any of the following:
(a) Create, modify, or revoke a trust;
(b) Fund with your property a trust not created by you or a person authorized to create
a trust for your benefit;
(c) Make or revoke a gift of your property in trust or otherwise;
(d) Create or change rights of survivorship in your property or in property in which you
may have an interest;
(e) Designate or change the designation of a beneficiary to receive any property,
benefit, or contractual right on your death, such as insurance benefits and
retirement benefits;
(f) Create in the agent or a person to whom the agent owes a legal duty of support the
right to receive property, a benefit, or a contractual right in which you have an
interest;
(g) Delegate the powers granted under the power of attorney to another person.
(h) Elect or change a retirement allowance plan of payment on your behalf under Ohio
Revised Code Chapter 145., 742., 3305., 3307., 3309., or 5505., other than a joint
and survivor annuity leaving one-half to your spouse if you are married, a single life
annuity if you are single, or any plan that includes a partial lump sum option; except
that no express authority is necessary to elect a plan that meets the minimum
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requirements of a court order to elect a plan that will pay a lifetime benefit to a
former spouse.
(i) If authorized under Ohio Revised Code section 145.814 [145.81.4], change an
election made under Ohio Revised Code sect ion 145.19 or 145.191 [145.19.1].
(j) Terminate your membership in the public employees retirement system, state
teachers retirement system, school employees retirement system, Ohio police and
fire pension fund, or state highway patrol retirement system by withdrawing your
accumulated employee contributions.
The powers that you give to your agent are explained more fully in Ohio Revised Code
sections 1337.19 and 1337.20. If you have any questions about this document or the powers
that you are giving to your agent, you should obtain legal advice.
2. Notice to Agent.
Once you accept designation as the agent under this document or exercise authority
granted to you by the principal, a fiduciary relationship is cr eated between you and the principal.
Unless otherwise modified in this power of attorney, your duties include the duty to do all of the
following:
(a) Act in good faith, with reasonable care for the best interests of the principal;
(b) Take no action beyond the scope of the authority given to you in this document;
(c) Keep complete record of all receipts, disbursements, and transactions conducted for
the principal.
If you violate the terms of this document or the fiduciary duties created by this
relationship, you will be liable to the principal or the principal's successors for loss or damage
caused by your violation.
If there is anything about this document or your duties that you do not understand, you
should obtain legal advice.
3. Designation of Agent(s).
I, the above-named principal, hereby appoint and designate the following as my
Attorney(s)-in-Fact. (Insert the name(s), address(es), and telephone number(s) of your agent(s)
below. If more space is needed, you may attach additional sheets.)
Name: ____________________________
Address: __________________________
_________________________________
Telephone: ________________________
Name: ____________________________
Address: __________________________
_________________________________
Telephone: ________________________
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4. Designation of Successor Agent(s).
(Optional: acts if any named Agent dies, resigns, or is otherwise unable to act or serve.)
I, the above-named principal, hereby appoint and designate the following as my
successor Agent(s).
First Successor:
Name: ____________________________
Address: __________________________
_________________________________
Telephone: ________________________
Second Successor:
Name: ____________________________
Address: __________________________
_________________________________
Telephone: ________________________
[If more than one Agent is designated, check the box in front of one of the following statements.]
Each Agent may independently exercise the powers granted.
All Agents must jointly exercise the powers granted.
A majority in number of Agents must jointly exercise the powers granted.
Any person can rely on a statement by a successor Agent that he or she is properly
acting under this document and may rely conclusively on any action or decision made by that
successor Agent. That person does not have to make any further investigation or inquiry.
5. Grant of Pow er.
I, the above-named Principal hereby appoint the above named Agent(s) to act as my
agent(s) in any way that I could act with respect to the following matters, as each of them is
defined in Ohio Revised Code section 1337.20:
[To grant all of the following powers, initial the line in front of (W) and ignore the lines in front of
the other powers. To grant one or more, but fewer than all, of the following powers, initial the
line in front of each power you are granting. To withhold a power, do not initial the line in front of
it. You may, but need not, cross out each power withheld.]
Initial
__________ (A) Real property transactions
__________ (B) Tangible personal property transactions
__________ (C) Stock and bond transactions
__________ (D) Commodity and option transactions
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__________ (E) Banking and other financial institution transactions
__________ (F) Business operating transactions
__________ (G) Proprietary interests and materials transactions
__________ (H) Insurance and annuity transactions
__________ (I) Retirement plan transactions
__________ (J) Safe deposit box transactions
__________ (K) Estate, trust, and other beneficiary transactions
__________ (L) Borrowing transactions
__________ (M) Fiduciary transactions
__________ (N) Personal relationships and affairs
__________ (O) Benefits from Social Security, Medicare, Medicaid, and other
governmental programs, or military service
__________ (P) Records, reports, and statements
__________ (Q) Tax matters
__________ (R) Licenses
__________ (S) Access to documents
__________ (T) Employment of agents
__________ (U) Power to delegate
__________ (V) Claims and litigation
__________ (W) All powers listed above
Special Instructions:
[On the following lines or on additional pages you may give special instructions limiting or
extending the powers granted to your Agent.]
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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6. Commencement and Duration of Power.
This power of attorney is effective:
[Check the appropriate box below to the left of your choice. If you do not check any box, this
power of attorney will become effective when you sign it.]
Immediately.
Upon my incapacity as determined by the following person or persons and set forth in
an affidavit:
____________________________________________________________________
____________________________________________________________________
Upon my incapacity as determined by the following person or persons and set forth in
an affidavit:
____________________________________________________________________
____________________________________________________________________
Upon the following future date or event:
____________________________________________________________________
____________________________________________________________________
This power of attorney shall terminate:
[Check the appropriate box below to the left of your choice. If you do not check any box, this
power of attorney will terminate upon your death.]
Upon my death.
Upon my incapacity as determined by the following person or persons and set forth in
an affidavit:
____________________________________________________________________
____________________________________________________________________
Upon my incapacity as determined by two physicians and set forth in an affidavit.
Upon the following future date or event:
____________________________________________________________________
____________________________________________________________________
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7. Durability of Power.
[The authority granted in this power of attorney can be effective even during a period of
disability. Check the appropriate box below if you want this power of attorney to be effective or
to not be effective during any period of disability.]
This power of attorney will contin ue in force and effect even during any period in
which I am disabled.
This power of attorney will not be in force and will have no effect during any p eriod in
which I am disabled.
8. Obtaining Personal Health Information.
My Agent shall be treated as my personal representative for all purposes relating to
my Personal Health Information as provided in 45 CFR 164.502(g)(2) and for the
Health Insurance Portability and Accountability Act of 1996.
My Agent shall not be treated as my personal representative for any purposes relating
to my Personal Health Information as provided in 45 CFR 164.502(g)(2) and for the
Health Insurance Portability and Accountability Act of 1996.
9. Compensation of Agent.
[Your Agent will be reimbursed for all reasonable expen s es incurred in acting under this power
of attorney. Check the appropriate box below to indicate whether you want your Agent also to
be reasonably paid or not to be paid for services rendered as Agent.]
My Agent is entitled to reasonable compensation for services rendered as Agent
under this power of attorney.
My Agent shall not receive any compensation for services rendered as Agent under
this power of attorney.
10. Exoneration of Agent(s).
My Agent is released from any liability to me and my estate arising out of the acts or
failures to act of my Agent, except for willful misconduct or gross negligence. I agree to
indemnify and hold my Agent harmless against any liability or expense, including attorney's
fees, that my Agent may incur as the result of acting or failing to act under this instrument,
except for liability and expense resulting from willful misconduct or gross negligence.
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11. Exoneration of Third Parties.
I agree that any third party who receives a copy of this document may act under it.
Revocation of the power of attorney is not effective as to a third party until the third party learns
of the revocation. I agree to indemnify the third party for any claims that arise against the third
party because of reliance on this power of attorney.
12. Self-Dealing.
[With respect to the Agent's right to or not to enter into transactions with you, check the box in
front of one of the following statements.]
My Agent can enter into transactions with me or in my behalf in which my Agent is
personally interested as long as the terms of the transaction are fair to me,
notwithstanding any law prohibiting acts of self-dealing.
My Agent cannot enter into transactions with me or in my behalf in which my Agent is
personally interested.
13. Property to Which this Instrument Applies.
[Your Agent will have authority over some or all of your property. Check the appropriate box
below to indicate whether your Agent's authority is over all of your property or over only some of
your property. If your Agent's authority is over only some of your property, identify the property
not subject to this power of attorney.]
This instrument will apply to all of my property, real or personal, wherever located.
This instrument will apply to all of my property, real or personal, wherever located
except for the following:
[On the following lines or on additional pages you may list property not subject to this power of
attorney.]
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
14. Amending and Revocation.
I may amend or revoke this power of attorney at any time by a signed instrument
delivered to my Agent. If this instrument has been filed or recorded in public records, then any
amendment or revocation also will be similarly filed or recorded, but a similar filing or recording
of the amendment or revocation will not be necessary to effectuate the amendment or
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revocation with respect to my Agent and to all persons who have actual knowledge of the
amendment or revocation.
15. Nomination of Guardian.
[With respect to your right to nominate a guardian of your person or estate, or both, check the
box in front of one of the following statements.]
If a guardian or conservator is ever needed for my estate, I nominate my Agent or any
other person that my Agent nominates as my guardian or conservator. This
nomination revokes any other nomination I may have made in any other document
dated prior to the date of this power of attorney, including any nomination set forth in a
Health Care Durable Power of Attorney.
If a guardian or conservator is ever needed for my estate, I nominate
__________________________________________ as my guardian or conservator.
This nomination revokes any other nomination I may have made in any other
document dated prior to the date of this power of attorney, including any nomination
set forth in a Health Care Durable Power of Attorney.
I do not nominate any person as the guardian or conservator of my estate under this
instrument.
16. Governing Law.
The laws of the State of Ohio will govern all questions pertaining to the validity and
construction of this power of attorney.
IN WITNESS WHEREOF, I have signed this Power of Attorney on [Date] __________________
______________________________________
(Principal's Signature)
[This instrument should be notarized or witnessed, or both, as applicable law may require or as
may be desired.]
On _______________ [Date], this instrument was signed by ____________________________
[Name of Principal] in our presence and was acknowledged and declared by the Principal to be
the Principal's Power of Attorney. Immediately thereafter, at the Pr incipal's request, in the
Principal's presence, and in the presence of each other, we signed this instrument as
subscribing witnesses.
__________________________________ ________________________________________
Witness Witness
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This document was acknowledged before me _______________ [Date] by
_______________________________ [Name of Principal] who is known to me or from whom I
have obtained adequate proof of identity.
______________________________________
(Signature of notarial officer)
(Seal, if any)
______________________________________
(Title and Rank)
My commission expires: ___________________
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