Fillable Printable 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.

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.

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: