Fillable Printable Standard Durable Power of Attorney Form

Standard Durable Power of Attorney Form

NOTICE

The purpose of this power of attorney is to give the person you designate (your “Agent”) b road powe rs to

handle your prope rty, which may include powers to sell or otherwise di spose of any real or p ersonal

property without advance notice to you or approval by you.

This power of attorney does not impose a duty on your agent to exerci se granted powers, but when

powers are exerci sed, your agent must use d ue care to act for your benefit and in accordance with this

power of attorney.

Your agent may exercise the powers given here throughout your lifetime, even after you become

incapacitated, unless you expressly limit the duration of these po wers or you revoke the se p owers or a

court acting on your behalf terminates your agent’s authority.

Your agent must keep your funds separa te from your agent’s funds.

A court can take away the powers of yo ur agent if it finds your agent is not acting properly.

The powers and duties of an agent un der a power of attorney are explaine d more fully in 20 Pa.C.S.

Chapter 56.

If there is anything abo ut this form that you do not und erstand, you should ask a lawyer of your own

choosing to explain it to you.

I have read or had explain ed to me this notice and I understand its contents.

_______________________________ ______________________

Principal’s Name Date

Acknowledgement by Agent

The agent shall have no authority to act as agent under the power of attorney unless the agent has first

executed and affixed to the power of attorney the following a c knowledgem ent.

I, ____________________ ___________ , have read the attached po wer of attorney and am the person

identified as the agent for the principal. I hereby acknowledge that in the absence of a specific provision

to the contrary in the power of attorney or in 20 Pa. C.S. when I act as agent:

I shall exercise the powers for the benefit of the princip al.

I shall keep the asset s of the princip al separate from my assets.

I shall exercise reasonable caution and prudence.

I shall keep a full and accurate reco rd of all action, re ceipts, and disbursements on behalf of the

principal.

_________________________________ __________________________

Agent Date

DURABLE POWER OF ATTORNEY

I, ____________________ ___________ _, hereby revoke any general po wer of attorney that I have

heretofore giv en to any person and do hereby ap point _____________________ ___________ _______

to be my true and lawful Agent for me and on my behalf to perform all such acts as my Agent in his/her

absolute discretion may deem advisable, as fully as I could do if personally present. This Power of

Attorney is durable and sha ll not be affected my subse quent disabilit y or incapacity .

I. Except as otherwise stated in this Power of Attorney, my Agent is given the fullest powers to act

on my behalf, including the following powers (cross out and initial the powers you do not

want to give):

• To make limited gifts.

• To create a trust for my benefit.

• To make additions to an ex isting trust for my benefit.

• To claim an elective share of the estate of my decea sed spouse.

• To disclaim any interest in property.

• To renounce fiduciary positions.

• To withdraw and receive the income or corpu s of a trust.

• To authorize my admission to a medical, nursing, resi dential, or similar facility and to enter

into agreements for my care.

• To authorize medical and surgical procedures.

• To engage in real property transactio ns.

• To engage in tangible personal property transactio ns.

• To engage in stock, bond, and other securities transactions.

• To engage in commodity and option transactions.

• To borrow money.

• To enter safe deposit boxes.

• To engage in insurance transactions.

• To engage in retirement plan transactio ns.

• To handle interests in estates and trusts.

• To pursue claims and litigation.

• To receive government benefits.

• To pursue tax matters.

• To make an anatomical gift of all or part of my body.

•

To make or do any of the following (use this space to list any additional powers you wa nt

your Agent to have): _____________ __________________ __________________ _____

_______________________________________________________________________

_________________________________________________________________

II. This Power of Attorney shall not expire by reason of lapse of time.

III. This Power of Attorney shal l be revoked by my giving my Agent written notification of the

revocation. This notice shall not be con si dered binding unless actually received. Notice shall be

deemed to have been re ceived if hand-d elivered o r if mailed via the United States Post Office or

other nationally-recognized parcel service usin g a delivery confirma tion or tracking receipt.

IV. My Agent shall have authority to make copies of this Power of Attorney and to certify and deliver

the copy or original to any person, entity, or government agency. I hereby agree that any third

party receiving a duly executed copy or facsimile of this Power of Attorney may act hereund er

and that revocation or term ination of the Power of Attorney shall be ineffective as to such third

party unless t he third party possesse s no tice or knowledge of such revocation or termin ation.

V. I willfully and voluntarily sign this document and I und erstand its purpo se.

________________________________ ______________________

Principal’s Signature Date

Statement a nd Signature of Witnesses.

We sign bel ow as witne sses. This d eclaration was signed in our presence. The declarant appears to be

of sound mind, and to be makin g this designation voluntarily, without duress, fra ud, or undue influen ce.

(

Two witnesses at least 18 years of age are required by Pennsylva nia law and should witness your

signature in each other’s prese nce. A person may not be a witness if he/she sign s this document on

behalf of and at the direction of a Principal.

_______________________________ ________________________________

Witness Signature Witness Signature

_______________________________ ________________________________

Print Name Print Name

Notarization (Optional)

Notarization of document is not required in Pennsylvania, but if the document is both witnes sed and

notarized, it is more likely to be honore d in some other states.

On this ______ day of ___________ ________, 20__ __, before me personally appeared the af oresaid

declarant, to me known to be the person described in and who exe cuted the fo regoing instru ment and

acknowledged that he/she executed the same as his/her free act and deed. IN WITNESS WHEREOF, I

have hereunto set my han d and affixed my official seal in the County of ______ ___________ _________,

Commonwealth of Pennsylvania, the day and year first above written.

______________________________ ___________________

Notary Public My Commission Expires