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Fillable Printable Sample Power of Attorney Statutory Short Form - New York

Fillable Printable Sample Power of Attorney Statutory Short Form - New York

Sample Power of Attorney Statutory Short Form - New York

Sample Power of Attorney Statutory Short Form - New York

N.Y. Statutory Short Form Power of Attorney
Effective 09/12/2010
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 docum ent 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, you should provide written notice of the revocation to your prior agent(s) and to any
third parties who may have acted upon it, including 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.assem bly.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.
(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.
N.Y. Statutory Short Form Power of Attorney
Effective 09/12/2010
( ) 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) an d 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.
You may provide for specific succession rules in this section. Insert specific succession
provisions here:
(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 does not revoke any Powers of Attorney previously
executed by me unless I have stated otherwise below, under “Modifications.”
If you do not intend to revoke your prior Powers of Attorney, and if you have granted the same
authority in this Power of Attorney as you granted to another agent in a prior Power of Attorney,
each agent can act separately unless you indicate under “Modifications” that the agents with the
same authority are to act together.
(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 m y agent(s) with respect to the f o llowing 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;
N.Y. Statutory Short Form Power of Attorney
Effective 09/12/2010
( ) (H) claims and litigation;
( ) (I) personal and family maintenance. If you grant your agent this authority, it will allow the
agent to make gifts that you customarily have made to individuals, including the agent, and charitable
organizations. The total amount of all such gifts in any one calendar year cannot exceed five hundred
dollars;
( ) (J) benefits from governmental programs or civil or m ilitary service;
( ) (K) health care billing and payment matters; r ecords, reports, and statem ents;
( ) (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 gifts
or changes to interests in your property. If you wish to grant your agent such authority, you
MUST complete the Statutory Gifts Rider.
(h) CERTAIN GIFTS TRANSACTIONS: STATUTORY GIFTS RIDER (OPTIONAL)
In order to authorize your agent to make gifts in excess of an annual total of $500 for all gifts
described in (I) of the grant of authority section of this document (under personal and family
maintenance), you must initial the statement below and execute a Statutory Gifts Rider at the
same time as this instrument. Initialing the statement below by itself does not authorize your
agent to make gifts. The preparation of the Statutory Gifts Rider should be supervised by a
lawyer.
(____) (SGR) I grant my agent authority to make gifts in accordance with the
terms and conditions of the Statutory Gifts Rider that supplements this statutory
Power of Attorney.
(i) DESIGNATION OF MONITOR(S): (OPTIONAL)
IF YOU WISH TO APPOINT MONITOR(S), INITIAL AND FILL IN THE SECTION
BELOW:
( ) I wish to designate , whose
address(es) is(are) ,
.
N.Y. Statutory Short Form Power of Attorney
Effective 09/12/2010
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.
N.Y. Statutory Short Form Power of Attorney
Effective 09/12/2010
(m) SIGNATURE AND ACKNOWLEDGMENT:
In Witness Whereof I have hereunto signed my name on ,20 .
PRINCIPAL signs here: ____________________________________________________
State of New York
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) 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 manners:
(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 anyone else or make gifts to
yourself or anyone else unless the principal has specifically granted you that authority in this
document, which is either a Statutory Gifts Rider attached to a statutory Short Form Power of
Attorney or a non-statutory 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.
N.Y. Statutory Short Form Power of Attorney
Effective 09/12/2010
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: _____________________________________________
_____________________________________________
State of New York
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
(p) SUCCESSOR AGENT’S SIGNATURE AND ACKNOWLEDGEMENT OF
APPOINTMENT:
It is not required that the principal and the successor agent(s), if any, sign at the same time, nor
that multiple successor agents sign at the same time. Furthermore, successor agents cannot use
this Power of Attorney unless the agent(s) designated above is/are unable or unwilling to serve.
I/we, , have read the foregoing Power of Attorney, I
am/we are the person(s) identified therein as successor 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 09/12/2010
State of New York
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 New York
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 09/12/2010
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 09/12/2010
POWER OF ATTORNEY
NEW YORK STATUTORY GIFTS RIDER
AUTHORIZATION FOR CERTAIN GIFT TRANSACTIONS
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 gifts in excess of an annual total of $500 for all gifts described in (I) of the grant of
authority section of the statutory short form Power of Attorney (under personal and family
maintenance), or certain other gift transactions during your lifetime. You do not have to execute
this rider if you only want your agent to make gifts described in (I) of the grant of authority
section of the statutory short form Power of Attorney and you initialed “(I)” on that section of
the form. 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. “Certain gift transactions” are described in section 5-1514 of the
General Obligations Law. This 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 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 gifts, 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 mu st 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 09/12/2010
(b) MODIFICATIONS:
Use this section if you wish to authorize gifts in amounts smaller than the gift tax exclusion
amount, in amounts in excess of the gift tax exclusion amount, gifts to other beneficiaries, or
other gift transactions.
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 GIFTS TO
HIMSELF OR HERSELF: (OPTIONAL)
If you wish to authorize your agent to make gifts 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 gifts 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 Statutory 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 09/12/2010
State of New York
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 Statutory 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 Statutory 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 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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