Fillable Printable Power of Attorney New York Statutory Short Form

Power of Attorney New York Statutory Short Form

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POWER OF ATTORNEY

NEW YORK STATUTORY SHORT FORM

(Effective 9-1- 2009)

__________________________________________________

(a) CAUTION TO THE PRINCIPAL

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 docu ment 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 by executing this Power of Attorney, you should provide written notice of the revocation

to your prior agent(s) and to 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.

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(b) DESIGNATION OF AGENT(S)

I, ___________________________________________________________________, hereby appoint:

(name and address of principal)

______________________________________________________________________ as my agent(s).

(name(s) and address(es) of agent(s))

If you designate more than one agent above, they must act together unless you initial the statement

below.

( ) My agents may act SEPARATELY.

If every agent designated above is unable or unwilling to serve, I appoint as m y successor agent(s):

__________________________________________________________________________________

(name(s) and address(es) of successor agent(s))

Successor agents designated above must act together unless you initial the statement below.

( ) My successor agents may act SEPARATELY.

(d) This POWER OF ATTORNEY shall not be affected by my subsequent incapacity unless I have

stated otherwise below, under "Modifications".

(e) This POWER OF ATTORNEY REVOKES any and all prior Powers of Attorney executed by me

unless I have stated otherwise below, under "Modifications." If you are NOT revoking your prior

Powers of Attorney, and if you are granting the same authority in two or more Powers of Attorney, you

must also indicate under "Modifications" whether the agents given these powers are to act together or

separately.

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(f) GRANT OF AUTHORITY

To grant your agent some or all of the authority below, either (1) Initial the bracket at each authority you

grant, or (2) Write or type the letters for each authority you grant on the blank line at (P), and initial the

bracket at (P). If you initial (P), you do not need to initial the other lines.

I grant authority to my agent(s) with respect to the following subjects as defined in sections 5-1502A

through 5-1502N of the New York General Obligations Law:

( ) (A) real estate transactions;

( ) (B) chattel and goods transactions;

( ) (C) bond, share, and commodity transactions;

( ) (D) banking transactions;

( ) (E) business operating transactions;

( ) (F) insurance transactions;

( ) (G) estate transactions;

( ) (H) claims and litigation;

( ) (I) personal and family maintenance;

( ) (J) benefits from governmental programs or civil or military service;

( ) (K) health care b illing and payment matters; records, reports, and statements;

( ) (L) retirement benefit transactions;

( ) (M) tax matters;

( ) (N) all other matters;

( ) (O) full and unqualified authority to my agent(s) to delegate any or all of the foregoing

powers to any person or persons whom my agent(s) select;

( ) (P) EACH of the matters identified by the following letters _____________________.

You need not initial the other lines if you initial line (P).

(g) MODIFICATIONS: (OPTIONAL)

In this section, you may make additional provisions, including language to limit or supplement authority

granted to your agent. However, you cannot use this Modifications section to grant your agent authority

to make major gifts or changes to interests in your property.

If you wish to grant your agent such authority, you MUST complete the Statutory Major Gifts Rider.

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(h) MAJOR GIFTS AND OTHER TRANSFERS:

STATUTORY MAJOR GIFTS RIDER (OPTIONAL)

In order to authorize your agent to make major gifts and other transfers of your property, you must

initial the statement below and execute a Statutory Major Gifts Rider at the same time as this instrument.

Initialing the statement below by itself does not authorize your agent to make major gifts and other

transfers. The preparation of the Statutory Major Gifts Rider should be supervised by a lawyer.

( ) (SMGR) I grant my agent authority to make major gifts and other transfers of my

property, in accordance with the terms and conditions of the Statutory Major Gifts

Rider that supplements this Power of Attorney.

(i) DESIGNATION OF MONITOR(S) : (OPTIONAL)

I wish to designate ___________________________________________________, whose address(es) is

(are) ________________________________________________________________, as monitor(s).

Upon the request of the monitor(s), my agent(s) must provide the monitor(s) with a copy of the power of

attorney and a record of all transactions done or made on my behalf. Third parties holding records of

such transactions shall provide the records to the monitor(s) upon request.

(j) COMPENSATION OF AGENT(S): (OPTIONAL)

Your agent is entitled to be reimbursed from your assets for reasonable expenses incurred on your

behalf. If you ALSO wish your agent(s) to be compensated from your assets for services rendered on

your behalf, initial the statement below. If you wish to define "reasonable compensation", you may do

so above, under "Modifications".

( ) My agent(s) shall be entitled to reasonable compensation for services rendered.

(k) ACCEPTANCE BY THIRD PARTIES

I agree to indemnify the third party for any claims that may arise against the third party because of

reliance on this Power of Attorney. I understand that any termination of this Power of Attorney,

whether the result of my revocation of the Power of Attorney or otherwise, is not effective as to a third

party until the third party has actu al notice or knowledge of the termination.

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(l) TERMINATION

This Power of Attorney continues until I revoke it or it is terminated by my death or other event

described in section 5-1511 of the General Obligations Law. Section 5-1511 of the General Obligations

Law describes the manner in which you may revoke your Power of Attorney, and the events which

terminate the Power of Attorney.

(m) SIGNATURE AND ACKNOWLEDGMENT:

In Witness Whereof I have hereunto signed my name this __________ day of __________, 20___.

(PRINCIPAL SIGNS HERE:) ►__________________________________________

(Signature of Principal)

STATE OF NEW YORK :

: ss.:

COUNTY OF __________ :

On the __________ day of __________ in the year __________ before me, the undersigned, personally

appeared __________________________________________, personally known to me or proved to me

on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the

within instrument and acknowledged to me that he/she/they executed the same in his/her/their

capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person

upon behalf of which the individual(s) acted, executed the instrument.

_____________________________

Notary Public

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(n) 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 manner:

(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 give major gifts to yourself or anyone else

unless the principal has specifically granted you that authority in this Power of Attorney or in a Statutory

Major Gifts Rider attached to this 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 5. 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.

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(o) AGENT'S SIGNATURE AND ACKNOWLEDGMENT OF APPOINTMENT

It is not required that the principal and the agent(s ) sign at the same time, nor that multiple agents sign at

the same time.

I/we, _____________________________________________________________________________,

have read the foregoing Power of Attorney. I am/we are the person(s) identified therein as agent(s) for

the principal named therein.

I/we acknowledge my/our legal responsibilities.

(AGENT SIGNS HERE:) ►__________________________________________

(Signature of Agent)