Fillable Printable Statutory Short Form of Durable General Power of Attorney - New York

Statutory Short Form of Durable General Power of Attorney - New York

N.Y. Statutory Short Form Power of Attorney

Effective 9/12/2010

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 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, 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.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 9/12/2010

(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 any 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.

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.

N.Y. Statutory Short Form Power of Attorney

Effective 9/12/2010

(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 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. 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 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

gifts or changes to interests in your property. If you wish to grant your agent such authority,

you MUST complete the Statutory Gifts Rider.

________________________________________________________________________________

N.Y. Statutory Short Form Power of Attorney

Effective 9/12/2010

(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)________________________________________________________________,

_______________________________________________________________________________.

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.

N.Y. Statutory Short Form Power of Attorney

Effective 9/12/2010

(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) 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).

N.Y. Statutory Short Form Power of Attorney

Effective 9/12/2010

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.

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___________)

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 9/12/2010

(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 can

not 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.

Successor Agent(s) sign (s) 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

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 9/12/2010

Recorded at Request of First American

Title Insurance Company of New York

RETURN BY MAIL TO:

Affidavit

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

N.Y. Statutory Gifts Rider

Effective 9/12/2010

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 that 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 must separately grant

that authority in subdivision (c) below.

N.Y. Statutory Short Form Power of Attorney

N.Y. Statutory Gifts Rider

Effective 9/12/2010

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.

(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 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 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:

________________________________________________________________________________