Fillable Printable Uniform Statutory Form Power of Attorney - California

Uniform Statutory Form Power of Attorney - California

UNIFORM STATUTORY FORM POWER OF ATTORNEY

(California Probate Code Section 4401)

NOTICE: THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD

AND SWEEPING. THEY ARE EXPLAINED IN THE UNIFORM STATUTORY

FORM POWER OF ATTORNEY ACT(CALIFORNIA PROBATE CODE

SECTIONS 4400-4465). IF YOU HAVE ANY QUESTIONS ABOUT THESE

POWERS, OBTAIN COMPETENT LEGAL ADVICE. THIS DOCUMENT DOES

NOT AUTHORIZE ANYONE TO MAKE MEDICAL ANDOTHERHEALTH-

CARE DECISIONSFORYOU. YOU MAY REVOKE THIS POWER OF

ATTORNEY IF YOU LATER WISH TO DO SO.

I, , who currently reside at

appoint

,who currently resides at

or if that person

is no longer willing or able, who currently resides at

or if that person

is no longer willing or able who currently resides at

asmy agent

(attorney-in-fact) toact for me in any lawfulway withrespectto the following

initialed subjects:

TO GRANT ALL OF THE FOLLOWING POWERS, INITIAL THE LINE IN

FRONT OF (N) AND IGNORE THE LINESIN FRONT OF THE OTHER

POWERS.

TO GRANT ONE OR MORE, BUT FEWER THAN ALL OF THE

FOLLOWING POWERS, INITIAL THE LINE IN FRONT OF EACH POWER YOU

ARE GRANTING.

TO WITHHOLD A POWER, DO NOT INITIAL THE LINE IN FRONT OF

IT. YOU MAY, BUT NEED NOT, CROSS OUT EACH POWER WITHHELD.

INITIAL

(A)Real Property transactions

(B)Tangible personal property transactions.

(C)Stock and bond transactions.

(D)Commodity and option transactions.

(E)Banking and other financial institution transactions.

(F)Business operating transactions.

(G)Insurance and annuity transactions.

(H)Estate, trust, and other beneficiary transactions.

(I)Claims and litigation.

(J)Personal and family maintenance.

(K)Benefitsfromsocialsecurity,medicare,medicaid,orother

governmental programs, or civil or military service.

(L)Retirement plan transactions.

(M) Tax matters.

(N)ALL OF THE POWERS LISTED ABOVE.

YOU NEED NOT INITIAL ANY OTHER LINES IF YOU INITIAL LINE

(N).

SPECIAL INSTRUCTIONS:

ON THE FOLLOWING LINES YOU MAY GIVE SPECIAL

INSTRUCTIONS LIMITING OR EXTENDING THE POWERS GRANTED TO

YOUR AGENT.

A.Thepowers grantedmy agent hereinshall only be effective uponmy

incapacity.

B.For purposes of this Power of Attorney,incapacity, shallbe determined

by twolicensedphysicians not related tome or any of my nominated

agents by blood or marriage pursuant toCalifornia Probate Code

Sections 4129 and 4405.

C.Myagent shall cooperate withmy lawfullyappointedagent for health

care under my Advance HealthCare Directive or any partymaking

health care decisionsfor me byreleasingfundsfrommy estate if

necessary to payfor any treatment or care lawfully designated bymy

agent for health care.

UNLESS YOU DIRECT OTHERWISE ABOVE, THIS POWER OF

ATTORNEY IS EFFECTIVE IMMEDIATELY AND WILL CONTINUE UNTIL IT

IS REVOKED.

This power of attorney will continue to be effective thoughIbecome

incapacitated.

STRIKE THE PRECEDING SENTENCE IFYOU DO NOT WANT THIS

POWER OF ATTORNEY TO CONTINUE IF YOU BECOME INCAPACITATED.

EXERCISE OF POWER OF ATTORNEY WHERE

MORE THAN ONE AGENT DESIGNATED

IF YOU APPOINTED MORE THANONE AGENT AND YOU WANT

EACH AGENT TO BE ABLE TO ACT ALONE WITHOUT THE OTHER AGENT

JOINING, WRITE THE WORD "SEPARATELY" IN THE BLANK SPACE

ABOVE. IF YOU DO NOT INSERT ANY WORD IN THE BLANK SPACE, OR IF

YOU INSERT THE WORD "JOINTLY," THEN ALL OF YOUR AGENTS MUST

ACT OR SIGN TOGETHER.

I agree thatanythirdparty who receives a copy of this documentmay actunder

it. Revocation of the power of attorney is not effective as to a third party until

the third party has actual knowledge of the revocation. I agree to indemnify the

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thirdpartyfor any claims thatarise againstthe thirdparty because of reliance on this

power of attorney.

Signed this day of , 20 .

(your signature)

(your social security number)

State of California,

County of ______________

BY ACCEPTING OR ACTING UNDER THE APPOINTMENT, THE AGENT

ASSUMES THE FIDUCIARY AND OTHER LEGAL RESPONSIBILITIES OF AN

AGENT.

CERTIFICATE OF ACKNOWLEDGMENT

STATE OF CALIFORNIA )

COUNTY OF _________________ )

On ___________________, before me, ,

a notary public, personally appeared who proved

tome on the basisof satisfactory evidence tobe the personwhose name issubscribed

tothe within instrument and acknowledgedtome that he/she executedthe same in

his/her authorizedcapacity, and thatby his/her signature on the instrument the

person, or the entityuponbehalf of whichthe personactedexecuted the instrument.

Icertify under PENALTY OF PERJURY under the lawsof the State of California

that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Signature____________________________________