Fillable Printable 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.

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.

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:

___________________________________