Power of Attorney Form - Ohio - Edit, Fill, Sign Online

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: ___________________

Fillable Printable Power of Attorney Form - Ohio

Fillable Printable Power of Attorney Form - Ohio

Power of Attorney Form - Ohio