LIMITED POWER OF ATTORNEY

THIS LIMITED POWER OF ATTORNEY is given by_______________________________________

 (hereinafter “Principal”), an individual residing in the County of _____________________________, 

State of ___________________, Address of _____________________________________________,

Zip code __________________________.

I, the undersigned, do hereby appoint _____________________________________________, 

who resides at ______________________________________________________________________

______________________________________________________________________

to be my true and lawful ATTORNEY-IN-FACT (hereinafter “Agent”) with the following limited powers:

	
I authorize my Agent to execute, acknowledge, and deliver any instrument and do all things necessary to carry out the intent hereof, hereby granting to my Agent full power and authority to act in and concerning the premises as fully and effectually as I may do if present, provided, however that all business transacted by my Agent hereunder shall be transacted in my name, and that all endorsements and instruments executed by my Agent for the purpose of carrying out the foregoing powers shall contain my name, followed by that of my Agent, and the designation “Attorney-in-Fact.”

The effective date of this Power of Attorney is ______________________________________

My Agent shall not be liable for any loss that results from a judgment error that was made in good faith. However, my Agent shall be liable for willful misconduct or the failure to act in good faith while acting under the authority of this Power of Attorney. I authorize my Agent to bring suit against any third party that fails or refuses to honor this Power of Attorney. I authorize my Agent to indemnify and hold harmless any third party who accepts and acts under this Power of Attorney.

My Agent shall be entitled to reimbursement of all reasonable expenses incurred in connection with this Power of Attorney, be entitled to reasonable compensation on account of the services performed hereunder. My Agent shall provide an accounting for all funds handled and all acts performed as my Agent, if I so request or if such a request is made by any authorized personal representative or fiduciary acting on my behalf.

This Power of Attorney may be revoked by me at any time by written notice to my Agent. This Power of Attorney shall automatically be revoked upon my death.

IN WITNESS WHEREOF, I have executed this Power of Attorney on this ____ day of _________, 201__.

							
SIGNATURE OF PRINCIPAL

							
PRINTED NAME OF PRINCIPAL

Witness Signature:___________________________________

Name:_____________________________________________

Address:___________________________________________

Witness Signature:___________________________________

Name:_____________________________________________

Address:___________________________________________

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(THIS AREA FOR NOTARY PUBLIC)

		

ACCEPTANCE OF APPOINTMENT AS ATTORNEY-IN-FACT

NOTICE TO PERSON ACCEPTING THE APPOINTMENT AS ATTORNEY-IN-FACT:  

BY ACTING OR ACCEPTING THIS APPOINTMENT AS THE AGENT (ATTORNEY-IN-FACT) UNDER THIS POWER OF ATTORNEY, YOU ASSUME THE FIDUCIARY AND OTHER LEGAL RESPONSIBILITIES OF AN AGENT.  These responsibilities include:

1.	The legal duty to act solely in the interest of the Principal and to avoid conflicts of interest.

2.	The legal duty to keep the Principal’s property separate and distinct from any other property owned or controlled by you. You may not transfer the Principal’s property to yourself without a full and adequate consideration, or accept a gift of the Principal’s property, unless this Power of Attorney specifically authorizes you to transfer property to yourself or accept a gift of the Principal’s property. If you transfer the Principal’s property to yourself or accept a gift of the Principal’s property without specific authorization in the Power of Attorney, you may be prosecuted for fraud and/or embezzlement and/or elder abuse. In addition to criminal prosecution, you may also be sued in civil court.

I have read the foregoing notice, and I understand and accept the legal and fiduciary duties that I assume by acting or agreeing to act as the Attorney-in-Fact under the terms of this Power of Attorney.

DATE:						 	

							
SIGNATURE OF AGENT

							
PRINTED NAME OF AGENT