Fillable Printable Statutory Form Power of Attorney - Nebraska

Statutory Form Power of Attorney - Nebraska

Nebraska Statutory Form Power of Attorney

Important Information

This power of attorney authorizes another person (your agent) to make decisions

concerning your property for you (the principal). Your agent will be able to make

decisions and act with respect to your property (including your money) whether or not

you are able to act for yourself. The meaning of authority over subjects listed on this

form is explained in the Nebraska Uniform Power of Attorney act.

This power of attorney does not authorize the agent to make health care decisions for

you.

You should select someone you trust to serve as your agent. Unless you specify

otherwise, generally the agent’s authority will continue until you die or revoke the power

of attorney or the agent resigns or is unable to act for you.

This form will not revoke a power of attorney previously executed by you unless you add

that the previous power of attorney is revoked or that all other powers of attorney are

revoked by this power of attorney.

This form provides for designation of one agent. If you wish to name more than one

agent you may name a coagent in the special instructions. Coagents are not required

to act together unless you include that requirement in the special instructions.

If your agent is unable or unwilling to act for you, your power of attorney will end unless

you have named a successor agent. You may also name a second successor agent.

This power of attorney becomes effective immediately unless you state otherwise in the

special instructions.

If you have questions about the power of attorney or the authority you are granting to

your agent, you should seek legal advice before signing this form.

Designation of Agent

I _____________________ (name of principal) name the following person as my agent:

Name of agent ___________________________________

Agent’s address___________________________________

Agent’s telephone number __________________________

Designation of successor agent (optional)

Name of successor agent ____________________________

Successor Agent’s address ____________________________

Successor Agent’s Telephone number _____________________

If my successor agent is unable or unwilling to act for me, I name as my second

successor agent:

Name of Second successor agent ________________________

Second successor Agent’s Address ________________________

Second Successor Agent’s Telephone Number __________________

Release of Information

I agree to, authorize and allow full release of information, by any governmental

agency, business, creditor, or third party who may have information pertaining to my

assets or in come, to my agent name herein.

Grant of General Authority

I grant my agent and any successor agent general authority to act for me with

respect to the following subjects as defined in the Nebraska Uniform Power of Attorney

Act:

(INITIAL each subject you want to include in the agent’s general authority. If you

wish to grant general authority over all of the subjects you may initial “All Preceding

Subject” instead of initially each subject. )

____ Real Property

____ Tangible Personal Property

____Stocks and Bonds

____Commodities and Options

____ Banks and other Financial Institutions

____Operation of Entity or Business

____Insurance and Annuities

____Estates, Trusts, and Other Beneficial Interests

____Claims and Litigation

____Personal and Family Maintenance

____Benefits from Governmental Programs or Civil or Military Service

____Retirement Plans

____Taxes

____All Preceding Subjects

Grant of specific Authority (Optional)

My agent MAY NOT do any of the following specific acts for me UNLESS I have

INITILED the specific authority listed below:

(CAUTION: Granting any of the following will give your agent the authority to take

actions that could significantly reduce your property or change how your property is

distributed at your death. INITIAL ONLY the specific authority you WANT to give your

agent.)

____Create, amend, revoke, or terminate an inter vivos trust

____ Make a gift, subject to the limitations of the Nebraska Uniform Power of Attorney

Act and any special instructions in this power of attorney

____Create or change rights of survivorship

____Create or change a beneficiary designation

____Delegate to another person to exercise the authority granted under this power of

attorney

____Waive the principal’s right to be a beneficiary of a joint and survivor annuity,

including a survivor benefit under a retirement plan.

____Exercise fiduciary powers that the principal has authority to delegate

____ Renounce or disclaim an interest in property, including a power of appointment.

LIMITATION ON AGENT’S AUTHORITY

Except as otherwise authorized by the Power of Personal and Family Maintenance, an

agent MAY NOT use my property to benefit the agent or a person to whom the agent

owes an obligation of support unless I have included that authority in the Special

Instructions or the Grant of Specific Authority.

SPECIAL INSTRUCTIONS (OPTIONAL)

You may give special instructions on the following lines:

______________________________________________________________________

EFFECTIVE DATE

This power of attorney is effective immediately unless I have stated otherwise in the

Special Instructions.

NOMINATION OF [CONSERVATOR OR GUARDIAN]

(OPTIONAL)

If it becomes necessary for a court to appoint a [conservator or guardian] of my estate

or [guardian] of my person, I nominate the following person(s) for appointment:

Name of Nominee for [conservator or guardian] of my estate: ___________________

Nominee’s Address: ___________________________________________________

Nominee’s Telephone Number:___________________________________________

Name of Nominee for [guardian] of my person: ______________________________

Nominee’s Address: ___________________________________________________

Nominee’s Telephone Number: __________________________________________

Any person, including my agent, may rely upon the validity of this power of attorney or a

RELIANCE ON THIS POWER OF ATTORNEY

copy of it unless that person knows it has terminated or is invalid.

SIGNATURE AND ACKNOWLEDGMENT

____________________________________ _________________

Your Signature Date

____________________________________ ___________________________

Your Name Printed

____________________________________ ___________________________

Your Telephone Number Your Address

State of Nebraska

County of __________________

This document was acknowledged before me on _______________(Date) , by

_______________________________(Name of Principal).

________________________________

Signature of Notary

My commission expires: _____________

This document prepared by:

Legal Aid of Nebraska

IMPORTANT INFORMATION FOR AGENT

Agent’s Duties

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

upon you legal duties that continue until you resign or the power of attorney is

terminated or revoked. You must:

1. Do what you know the principal reasonably expects you to do with the principal’s

property or, if you do not know the principal’s expectations, act in the principal’s best

interest;

2. Act in good faith;

3. Do nothing beyond the authority granted in this power of attorney; and

4. Disclose your identity as an agent whenever you act for the principal by writing or

printing the name of the principal and signing your own name as "agent" in the following

manner:

(Principal’s Name) by (Your Signature) as Agent, unless the Special Instructions in this

power of attorney state otherwise, you must also:

1. Act loyally for the principal’s benefit;

2. Avoid conflicts that would impair your ability to act in the principal’s best interest;

3. Act with care, competence, and diligence;

4. Keep a record of all receipts, disbursements, and transactions made on behalf of the

principal;

5. Cooperate with any person that has authority to make health care decisions for the

principal to do what you know the principal reasonably expects or, if you do not know

the principal’s expectations, to act in the principal’s best interest; and

6. Attempt to preserve the principal’s estate plan if you know the plan and preserving

the plan is consistent with the principal’s best interest.

Termination of Agent’s Authority

You must stop acting on behalf of the principal if you learn of any event that terminates

this power of attorney or your authority under this power of attorney. Events that

terminate a power of attorney or your authority to act under a power of attorney include:

1. Death of the principal;

2. The principal’s revocation of the power of attorney or your authority;

3. The occurrence of a termination event stated in the power of attorney;

4. The purpose of the power of attorney being fully accomplished; or

5. If you are married to the principal, a legal action filed with a court to end your

marriage, or for your legal separation, unless the Special Instructions in this power of

attorney state that such an action will not terminate your authority.

Liability of Agent

The meaning of the authority granted to you is defined in the Nebraska Uniform Power

of Attorney Act. If you violate the Nebraska Uniform Power of Attorney Act or act outside

the authority granted, you may be liable for any damages caused by your violation.

If there is anything about this document or your duties that you do not understand, you

should seek legal advice.

OPTIONAL SIGNATURE OF AGENT

I HAVE READ AND ACCEPT THE DUTIES AND LIABILITIES OF THE AGENT AS

SPECIFIED IN THIS POWER OF ATTORNEY

Agent’s Signature: _____________________________

Date: ____________

AGENT’S CERTIFICATION AS TO THE VALIDITY OF POWER OF

ATTORNEY AND AGENT’S AUTHORITY

State of Nebraska

County of ________________________

I, ________________________________(Name of Agent), certify under penalty of

perjury that ________________________ (Name of Principal) granted me authority as

an agent or successor agent in a power of attorney dated ____________________ .

I further certify that to my knowledge:

(1) The Principal is alive and has not revoked the Power of Attorney or my authority to

act under the Power of Attorney and the Power of Attorney and my authority to act

under the Power of Attorney have not terminated;

(2) If the Power of Attorney was drafted to become effective upon the happening of an

event or contingency, the event or contingency has occurred;

(3) If I was named as a successor agent, the prior agent is no longer able or willing to

serve; and

(4) (Insert other relevant statements)

______________________________________________________________________

SIGNATURE AND ACKNOWLEDGMENT

_________________________________ _________________________

Agent’s Signature Date

__________________________________

Agent’s Name Printed

___________________________________

___________________________________ _________________________

Agent’s Address Agent’s Telephone Number

This document was acknowledged before me on ______________(Date), by

_________________________(Name of Agent).

Seal _____________________________

Signature of Notary

My commission expires: __________

This document prepared by:

Legal Aid of Nebraska