I, ________(1)________, of ________(2)________, hereby appoint
________(3)________ of ________(4)________, as my attorney in
fact to act in my capacity to do any and all of the following:
(DESCRIBE THE EXTENT OF AUTHORITY YOU ARE GIVING TO YOUR
ATTORNEY-IN-FACT) The rights, powers, and authority of my
attorney in fact to exercise any and all of the rights and
powers herein granted shall commence and be in full force and
effect on ________(5)________, 19_(6)_, and shall remain in
full force and effect until ________(7)________ or unless
specifically extended or rescinded earlier by either party.
Dated ___________(8)______________, 19__(9)__.
SIGNED _________(10)___________
STATE OF _______(11)____________
COUNTY OF ______(12)____________
BEFORE ME, the undersigned authority, on this _(13)_ day of
______(14)_______, 19_(15)_, personally appeared
________(16)________ to me well known to be the person
described in and who signed the Foregoing, and acknowledged
to me that he executed the same freely and voluntarily for
the uses and purposes therein expressed. WITNESS my hand and
official seal the date aforesaid.
_______________(17)_______________
NOTARY PUBLIC
My Commission Expires:____(18)____
1. Your full name
2. County or city in which you reside
3. Full name of person you appoint
4. County or city in which they reside
5. Day and month this becomes effective
6. Year this becomes effective
7. Last day, month and year this is effective
8. Day and month in which you signed it
9. The year in which you signed it
10. Your full signature
11. The state in which you reside
12. The county in which you reside
FILLED OUT BY NOTARY PUBLIC
13. Day you signed the form
14. Month you signed the form
15. Year you signed the form
16. Your full name
17. Notary Public signature
18. Notary Public commission expiration date
NOTICE
The information in this document is designed to provide an outline that you can follow when formulating business or personal plans. Due to the variances of many local, city, county and state laws, we recommend that you seek professional legal counseling before entering into any contract or agreement.
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