POWEROFATTORNEY
NEWYORKSTATUTORYSHORTFORM
(a)CAUTIONTOTHEPRINCIPAL:
YourPowerofAttorneyisanimportantdocument.Asthe“principal,”yougivetheperson whomyouchoose(your “agent”)authoritytospendyourmoneyandsellordisposeofyour propertyduringyourlifetimewithouttellingyou.Youdonotloseyourauthoritytoacteven thoughyouhavegivenyouragentsimilarauthority.
Whenyouragentexercisesthisauthority, heorshemustactaccordingtoanyinstructionsyou haveprovidedor,wheretherearenospecificinstructions,inyourbestinterest.“Important InformationfortheAgent”attheendofthisdocumentdescribesyouragent’s
responsibilities.
YouragentcanactonyourbehalfonlyaftersigningthePowerofAttorneybeforeanotary public.
Youcanrequestinformationfromyouragentatanytime.IfyouarerevokingapriorPowerof
Attorney,you shouldprovidewrittennoticeof therevocationtoyour prioragent(s)andtoany
thirdpartieswho mayhaveactedupon it,includingthefinancialinstitutionswhereyour accounts arelocated.
YoucanrevokeorterminateyourPowerofAttorneyatanytimeforanyreasonaslongasyou areofsoundmind.Ifyouarenolongerofsoundmind,acourtcanremoveanagentforacting improperly.
Youragentcannotmakehealthcaredecisionsforyou.Youmayexecutea“HealthCareProxy”
todothis.
ThelawgoverningPowersofAttorneyiscontainedintheNewYorkGeneralObligationsLaw, Article5,Title15.Thislawisavailableatalawlibrary,oronlinethroughtheNewYorkState SenateorAssemblywebsites,
us.
Ifthereisanythingaboutthisdocumentthatyoudonotunderstand,youshouldaskalawyerof yourownchoosingtoexplainit toyou.
(b)DESIGNATIONOFAGENT(S):
I,,hereby appoint: [nameandaddressofprincipal]
[name(s)andaddress(es)ofagent(s)]
asmyagent(s)
Ifyoudesignatemorethanoneagentabove,theymustacttogetherunlessyouinitialthe statementbelow.
()MyagentsmayactSEPARATELY.
(c)DESIGNATIONOFSUCCESSORAGENT(S):(OPTIONAL)
Ifeveryagentdesignatedaboveisunableorunwillingtoserve,Iappointasmysuccessor agent(s):
[name(s)andaddress(es)ofsuccessoragent(s)]
Successoragentsdesignated abovemustacttogetherunlessyouinitialthestatement below.
()MysuccessoragentsmayactSEPARATELY.
You mayprovidefor specificsuccessionrulesinthissection.Insertspecificsuccession provisionshere:
(d)ThisPOWEROFATTORNEYshallnotbeaffectedbymysubsequentincapacityunlessI
havestatedotherwisebelow,under ‘Modifications”.
(e)This POWEROFATTORNEYdoes notrevokeanyPowers of Attorneypreviouslyexecuted
bymeunlessIhavestatedotherwisebelow,under “Modifications.”
If you do notintendtorevokeyour priorPowers of Attorney,andifyou havegrantedthesame authorityinthisPower of Attorneyas you grantedtoanotheragentinapriorPower of Attorney, eachagentcanactseparatelyunless indicatedunder"Modifications"thattheagentswiththesame authorityaretoacttogether.
(f)GRANTOFAUTHORITY:
Tograntyouragentsomeoralloftheauthoritybelow,
either(1)Initialthebracketateachauthorityyougrant,or
(2)Writeortypethelettersforeachauthorityyougrantontheblanklineat(P),and initialthebracketat(P).Ifyouinitial(P),youdonotneedtoinitialtheotherlines.
Igrantauthoritytomyagent(s)withrespecttothefollowingsubjectsasdefined insections5-
1502Athrough5-l502NoftheNewYorkGeneralObligationsLaw:
()(A)realestatetransactions;
()(B)chattel andgoods transactions;
()(C)bond, share,andcommoditytransactions; ()(D)bankingtransactions;
()(E)businessoperatingtransactions; ()(F)insurancetransactions;
()(G)estatetransactions;
()(H)claimsandlitigation;
() (I) personalandfamilymaintenance.If you grantyour agentthisauthority,itwillallowthe
agenttomakegiftsthatyou havecustomarilyhavemadetoindividuals,includingtheagent,and charitableorganizations.Thetotalamountof allsuch giftsinanyonecalendaryearcannotexceed fivehundreddollars;
()(J)benefitsfromgovernmentalprogramsorcivilormilitaryservice;
()(K)health carebillingandpaymentmatters;records,reports,andstatements; ()(L)retirementbenefittransactions;
()(M)taxmatters;
()(N)allothermatters;
()(O)fullandunqualifiedauthoritytomyagent(s)todelegateanyoralloftheforegoing powerstoanypersonorpersonswhommyagent(s)select;
()(P)EACHofthemattersidentifiedbythefollowingletters initialtheotherlinesifyouinitialline(P).
.Youneednot
(g)MODIFICATIONS:(OPTIONAL)Inthissection,you maymakeadditionalprovisions, includinglanguagetolimitorsupplementauthoritygrantedtoyouragent.However,you cannot use thisModificationssectiontograntyour agentauthoritytomakegiftsor changestointerests
inyour property.If you wish tograntyour agentsuch authority,you MUST complete theStatutoryGifts Rider.
(h) CERTAIN GIFTTRANSACTIONS: STATUTORY GIFTSRIDER:
(OPTIONAL)In ordertoauthorizeyour agenttomakegiftsinexcessof anannualtotalof $500
for allgiftsdescribedin(I) of thegrantof authoritysectionof thisdocument(underpersonaland familymaintenance),you mustinitialthestatementbelowandexecuteaStatutoryGifts Riderat thesametimeas thisinstrument.Initialingthestatementbelowby itselfdoes notauthorizeyour
agenttomakegifts.Thepreparationof theStatutoryGifts Ridershouldbesupervisedby alawyer.
() (SGR) I grantmyagentauthoritytomakegiftsinaccordancewiththetermsand conditionsof theStatutoryGifts RiderthatsupplementsthisstatutoryPower of Attorney.
(i)DESIGNATIONOFMONITOR(S):(OPTIONAL)
If you wish toappointmonitor(s),initialandfillinthesectionbelow:
() I wish todesignate
, whose address(es)
is(are) ,
asmonitor(s).Upontherequestofthemonitor(s),myagent(s)mustprovidethemonitor(s)with acopyofthepowerofattorneyandarecordofalltransactionsdoneormadeonmybehalf. Thirdpartiesholdingrecordsofsuchtransactionsshallprovidetherecordstothemonitor(s) uponrequest.
(j)COMPENSATIONOFAGENT(S):(OPTIONAL)
Youragentisentitledtobereimbursedfromyourassetsforreasonableexpensesincurredon
yourbehalf.IfyouALSOwishyouragent(s)tobecompensatedfromyourassetsforservices renderedonyourbehalf,initialthestatementbelow.Ifyouwishtodefine“reasonable compensation”,youmaydosoabove,under“Modifications.”
()Myagent(s)shallbeentitledtoreasonablecompensationforservices rendered.
(k)ACCEPTANCEBYTHIRDPARTIES:Iagreetoindemnifythethirdpartyforanyclaims thatmayariseagainstthethirdpartybecauseofrelianceonthisPowerofAttorney.Iunderstand thatanyterminationofthisPowerofAttorney,whethertheresultofmyrevocationofthePower ofAttorneyorotherwise,isnoteffectiveastoathirdpartyuntilthethirdpartyhasactualnotice orknowledgeofthetermination.
(l)TERMINATION:ThisPowerofAttorneycontinuesuntilIrevokeit orit isterminatedby mydeathorothereventdescribedinsection5-1511oftheGeneralObligationsLaw.Section5-
1511oftheGeneralObligationsLawdescribesthemannerinwhichyoumayrevokeyourPower ofAttorney,andtheeventswhichterminatethePowerof
Attorney.
(m)SIGNATUREANDACKNOWLEDGMENT:
InWitnessWhereofIhavehereuntosignedmynameon ,20. PRINCIPALsignshere:
Stateof Countyof ss.:
Onthe dayof intheyear beforeme,theundersigned,personally appeared ,personally knowntomeorprovedtome
onthebasisofsatisfactoryevidencetobetheindividual(s)whosename(s)is(are)subscribedto thewithininstrumentandacknowledgedtomethathe/she/theyexecutedthesamein his/her/theircapacity(ies),andthatbyhis/hertheirsignature(s)ontheinstrument,the individual(s),orthepersonuponbehalfofwhichtheindividual(s)acted,executedthe instrument.
SignatureandOfficeofindividualtakingacknowledgment
(n)IMPORTANTINFORMATIONFORTHEAGENT:
WhenyouaccepttheauthoritygrantedunderthisPowerofAttorney,aspeciallegalrelationship iscreatedbetweenyouandtheprincipal.Thisrelationship imposesonyoulegalresponsibilities thatcontinueuntilyouresignorthePowerofAttorneyisterminatedorrevoked.Youmust:
(1)act accordingtoanyinstructionsfromtheprincipal,or,wheretherearenoinstructions,inthe principal’sbestinterest;
(2)avoidconflictsthatwouldimpairyourabilitytoactintheprincipal’sbestinterest;
(3)keeptheprincipal’spropertyseparateanddistinctfromanyassetsyouownorcontrol,unless otherwisepermittedbylaw;
(4)keeparecordorallreceipts,payments, andtransactionsconductedfortheprincipal;and (5)discloseyouridentityasanagentwheneveryouactfortheprincipalbywritingorprinting theprincipal’snameandsigningyourownnameas“agent”ineitherofthefollowingmanner: (Principal’sName)by(YourSignature) asAgent,or(YourSignature) asAgentfor(Principal’s Name).
You maynotuse theprincipal’sassets tobenefityourselfor anyanyoneelseor makegiftstoyourself or anyoneelseunless theprincipalhas specificallygrantedyou thatauthorityinthisdocument,which is eitheraStatutoryGifts RiderattachedtoaShortFormPower of Attorneyor anon-statutoryPower of Attorney.If you havethatauthority,you mustactaccordingtoanyinstructionsof theprincipalor, wherethereareno such instructions,intheprincipal’sbestinterest.You mayresignby givingwritten
noticetotheprincipalandtoanyco-agent,successor agent,monitorifonehas beennamedinthisdocument,
ortheprincipal’sguardianifonehasbeenappointed. Ifthereisanythingaboutthisdocumentor yourresponsibilitiesthatyoudonotunderstand,youshouldseeklegal
advice.
Liabilityofagent:
ThemeaningoftheauthoritygiventoyouisdefinedinNewYork’sGeneralObligations Law, Article5,Title15.Ifit isfoundthatyouhaveviolatedthelaworactedoutsidetheauthority grantedtoyouinthePowerofAttorney,youmaybeliableunderthelawforyour
violation.
(o)AGENT’SSIGNATUREANDACKNOWLEDGMENT OFAPPOINTMENT:Itisnot requiredthattheprincipalandtheagent(s)signatthesametime,northatmultipleagentssignat thesametime.
I/we, ,havereadtheforegoingPowerof Attorney.Iam/wearetheperson(s)identifiedthereinasagent(s)fortheprincipalnamedtherein. I/weacknowledgemy/ourlegalresponsibilities.
Agent(s)sign(s)here:
Stateof _New York
Countyof ss.:
Onthe dayof intheyear beforeme,theundersigned,personally appeared ,personally knowntomeorprovedtome
onthebasisofsatisfactoryevidencetobetheindividual(s)whosename(s)is(are)subscribedto thewithininstrumentandacknowledgedtomethathe/she/theyexecutedthesamein his/her/theircapacity(ies),andthatbyhis/hertheirsignature(s)ontheinstrument,the individual(s),orthepersonuponbehalfofwhichtheindividual(s)acted,executedthe instrument.
SignatureandOfficeofindividualtakingacknowledgment
(p) SUCCESSOR AGENT'S SIGNATURE AND ACKNOWLEDGEMENT OFAPPOINTMENT:
Itisnotrequiredthattheprincipalandthesuccessor agent(s),ifany,signatthesametime,nor
thatmultiplesuccessor agentssignatthesametime.Furthermore,successor agentscannotuse this
Power of Attorneyunless theagent(s)designatedaboveis/areunableor unwillingtoserve.
I/we, ,havereadtheforegoingPowerof
Attorney.Iam/wearetheperson(s)identifiedthereinasagent(s)fortheprincipalnamedtherein.
I/weacknowledgemy/ourlegalresponsibilities.
Agent(s)sign(s)here:
Stateof _New York
Countyof ss.:
Onthe dayof intheyear beforeme,theundersigned,personally appeared ,personally knowntomeorprovedtome
onthebasisofsatisfactoryevidencetobetheindividual(s)whosename(s)is(are)subscribedto thewithininstrumentandacknowledgedtomethathe/she/theyexecutedthesamein his/her/theircapacity(ies),andthatbyhis/hertheirsignature(s)ontheinstrument,the individual(s),orthepersonuponbehalfofwhichtheindividual(s)acted,executedthe instrument.
SignatureandOfficeofindividualtaking acknowledgment
N.Y.StatutoryShortFormPowerofAttorney
Effective09-12-10
Stateof _New York
Countyof ss.:
Onthe dayof intheyear beforeme,theundersigned,personally appeared ,personally knowntomeorprovedtome
onthebasisofsatisfactoryevidencetobetheindividual(s)whosename(s)is(are)subscribedto thewithininstrumentandacknowledgedtomethathe/she/theyexecutedthesamein
his/her/theircapacity(ies),andthatbyhis/hertheirsignature(s)ontheinstrument,the individual(s),orthepersonuponbehalfofwhichtheindividual(s)acted,executedthe instrument.
SignatureandOfficeofindividualtakingacknowledgment
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