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Fillable Printable Power of Attorney Statutory Short Form - New York

Fillable Printable Power of Attorney Statutory Short Form - New York

Power of Attorney Statutory Short Form - New York

Power of Attorney Statutory Short Form - New York

N.Y. Statutory Short Form Power of Attorney
Effective 09-01-09
POWER OF ATTORNEY
NEW YORK STATUTORY SHORT FORM
(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 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 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.
N.Y. Statutory Short Form Power of Attorney
Effective 09-01-09
(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.
(c) DESIGNATION OF SUCCESSOR AGENT(S): (OPTIONAL)
If every agent designated above is unable or unwilling to serve, I appoint as my 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.
(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.
N.Y. Statutory Short Form Power of Attorney
Effective 09-01-09
I grant authority to my agent(s) with respect to the following subjects as defined in sections 5-
1502A through 5-l502N 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 billing 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.
(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.
N.Y. Statutory Short Form Power of Attorney
Effective 09-01-09
(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 actual notice
or knowledge of the termination.
(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 on ___________, 20____.
PRINCIPAL signs here: _______________________________________
State of _________________
County of _______________ ss.:
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.
________________________________________________
Signature and Office of individual taking
acknowledgment
N.Y. Statutory Short Form Power of Attorney
Effective 09-01-09
(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 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.
(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(s) sign(s) here: _____________________________________________
_____________________________________________
N.Y. Statutory Short Form Power of Attorney
Effective 09-01-09
State of _________________
County of _______________ ss.:
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.
________________________________________________
Signature and Office of individual taking
acknowledgment
State of _________________
County of _______________ ss.:
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.
________________________________________________
Signature and Office of individual taking
acknowledgment
RETURN BY MAIL TO:
N.Y. Statutory Short Form Power of Attorney
Effective 09-01-09
NEW YORK STATUTORY POWER OF ATTORNEY
AFFIDAVIT AS TO POWER OF ATTORNEY
STATE OF _______________________
COUNTY OF _____________________ss:
______________________________________, being duly sworn, deposes and says as follows:
1. This affidavit is made in connection with the (transfer)(mortgage) of property known as
____________________________________, in ____________________, New York to
_______________________________________________________________________.
2. I am (the)(an) agent named in the Power of Attorney (hereafter "Power of Attorney")
made by ____________________________________, as principal (the "Principal"),
dated _____________________.
3. I do not have actual notice that the Power of Attorney has been modified in any way that
would affect my ability to authorize or engage in the present transaction for which the
Power of Attorney is being used, or notice of any facts indicating that the Power of
Attorney has been so modified.
4. I do not have actual notice of the termination or revocation of the Power of Attorney, or
notice of any facts indicating that the Power of Attorney has been terminated or revoked,
and the Power of Attorney remains in full force and effect.
5. If the Principal has been my spouse, we are not divorced and our marriage has not been
annulled.
6. If I am a successor agent, the prior agent is no longer able or willing to serve.
____________________________________
Sworn to before me this _____ day
of ___________________, 20____.
____________________________
Notary Public
NOTE:
If multiple agents are appointed, an affidavit is to be executed by each
agent.
N.Y. Statutory Short Form Power of Attorney
Effective 09-01-09
POWER OF ATTORNEY
NEW YORK STATUTORY MAJOR GIFTS RIDER
AUTHORIZATION TO MAKE MAJOR GIFTS OR OTHER TRANSFERS
Attached to a New York Statutory Short Form Power of Attorney
dated ___________ made by ______________________
CAUTION TO THE PRINCIPAL:
This OPTIONAL rider allows you to authorize your agent
to make major gifts or other transfers of your money or other property during your lifetime.
Granting any of the following authority to your agent gives your agent the authority to take
actions which could significantly reduce your property or change how your property is
distributed at your death. “Major gifts or other transfers” are described in section 5-1514 of the
General Obligations Law. This Major Gifts Rider does not require your agent to exercise granted
authority, but when he or she exercises this authority, he or she must act according to any
instructions you provide, or otherwise in your best
interest.
This Major Gifts Rider and the Power of Attorney it supplements must be read together as a
single instrument.
Before signing this document authorizing your agent to make major gifts and other transfers, you
should seek legal advice to ensure that your intentions are clearly and properly
expressed.
(a) GRANT OF LIMITED AUTHORITY TO MAKE GIFTS:
Granting gifting authority to your agent gives your agent the authority to take actions which
could significantly reduce your property. If you wish to allow your agent to make gifts to himself
or herself, you must separately grant that authority in subdivision (c)
below.
To grant your agent the gifting authority provided below, initial the bracket to the left of the
authority.
( ) I grant authority to my agent to make gifts to my spouse, children and more remote
descendants, and parents, not to exceed, for each donee, the annual federal gift tax exclusion
amount pursuant to the Internal Revenue Code. For gifts to my children and more remote
descendants, and parents, the maximum amount of the gift to each donee shall not exceed twice
the gift tax exclusion amount, if my spouse agrees to split gift treatment pursuant to the Internal
Revenue Code. This authority must be exercised pursuant to my instructions, or otherwise for
purposes which the agent reasonably deems to be in my best
interest.
N.Y. Statutory Short Form Power of Attorney
Effective 09-01-09
(b) MODIFICATIONS:
Use this section if you wish to authorize gifts in excess of the above amount, gifts to other
beneficiaries or other types of transfers.
Granting such authority to your agent gives your agent the authority to take actions which could
significantly reduce your property and/or change how your property is distributed at your death.
If you wish to authorize your agent to make gifts or transfers to himself or herself, you must
separately grant that authority in subdivision (c) below.
( ) I grant the following authority to my agent to make gifts or transfers pursuant to my
instructions, or otherwise for purposes which the agent reasonably deems to be in my best
interest.
(c) GRANT OF SPECIFIC AUTHORITY FOR AN AGENT TO MAKE MAJOR GIFTS
OR OTHER TRANSFERS TO HIMSELF OR HERSELF: (OPTIONAL)
If you wish to authorize your agent to make gifts or transfers to himself or herself, you must
grant that authority in this section, indicating to which agent(s) the authorization is granted, and
any limitations and guidelines.
( ) I grant specific authority for the following agent(s) to make the following major gifts or
other transfers to himself or herself:
This authority must be exercised pursuant to my instructions, or otherwise for purposes which
the agent reasonably deems to be in my best
interest.
(d) 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 Major Gifts Rider.
(e) SIGNATURE OF PRINCIPAL AND ACKNOWLEDGMENT:
In Witness Whereof I have hereunto signed my name on __________________, 20____.
PRINCIPAL signs here: _______________________________________
N.Y. Statutory Short Form Power of Attorney
Effective 09-01-09
State of _________________
County of _______________ ss.:
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.
________________________________________________
Signature and Office of individual taking
acknowledgment
(f) SIGNATURES OF WITNESSES:
By signing as a witness, I acknowledge that the principal signed the Major Gifts Rider in my
presence and the presence of the other witness, or that the principal acknowledged to me that the
principal's signature was affixed by him or her or at his or her direction. I also acknowledge that
the principal has stated that this Major Gifts Rider reflects his or her wishes and that he or she
has signed it voluntarily. I am not named herein as a permissible recipient of major
gifts.
Signature of witness 1 Signature of witness 2
Date Date
Print Name Print Name
Address Address
City, State, Zip code City, State, Zip code
(g) THIS DOCUMENT PREPARED BY:
___________________________________
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