UNIFORM STATUTORY FORM POWER OF ATTORNEY
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, INCLUSIVE). IF YOU HAVE
ANY QUESTIONS ABOUT THESE POWERS, OBTAIN COMPETENT LEGAL ADVICE. THIS
DOCUMENT DOES NOT AUTHORIZE ANYONE TO MAKE MEDICAL AND OTHER HEALTH
CARE DECISIONS FOR YOU. YOU MAY REVOKE THIS POWER OF ATTORNEY IF YOU
LATER WISH TO DO SO.
hereby appoint __________________________________________________, of
as my agent and attorney-in-fact to act for me in any lawful way with respect to the following initialed subjects:
TO GRANT ALL OF THE FOLLOWING POWERS, INITIAL THE LINE IN FRONT OF (N)
AND IGNORE THE LINES IN 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
(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) _____ Benefits from social security, Medicare,
Medicaid, or other governmental programs, or civil or military service.
(L) _____ Retirement plan transactions.
(M) _____ Tax matters.
ALL OF THE POWERS LISTED ABOVE. (YOU NEED NOT INITIAL ANY OTHER LINES IF YOU INITIAL LINE (N).)
ON THE FOLLOWING LINES YOU MAY GIVE SPECIAL INSTRUCTIONS LIMITING OR
EXTENDING THE POWERS GRANTED TO YOUR AGENT. UNLESS YOU DIRECT OTHERWISE
ABOVE, THIS POWER OF ATTORNEY IS EFFECTIVE IMMEDIATELY AND WILL
CONTINUE UNTIL IT IS REVOKED.
______This power of attorney shall become effective upon my incapcitation
______This power of attorney shall not be affected by my subsequent incapacity
UNLESS YOU DIRECT OTHERWISE ABOVE THIS POWER OF ATTORNEY IS EFFECTIVE IMMEDIATELY AND WILL CONTINUE UNTIL IT IS REVOKED.
EXERCISE OF POWER OF ATTORNEY WHERE MORE THAN ONE AGENT DESIGNATED
If I have designated more than one agent, the agents are to act separately or jointly.
IF YOU APPOINTED MORE THAN ONE 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 that any third party who receives a copy of this document may
act under 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 third party for the claims that
arise against the third party because of reliance on this power of
On ______________, 200___
(Social Security Number) ______________________
BY ACCEPTING OR ACTING UNDER THE APPOINTMENT, THE AGENT ASSUMES THE FIDUCIARY AND OTHER LEGAL RESPONSIBILITIES OF AN AGENT.
State of _______________County of
On_______ before me, __________________________________ personally appeared
_______________________________________ personally known to me
______________________________________ proved to me on the basis of satisfactory
evidence to be the person(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 authorized capacity(ties), and that by
his/her/their signature(s) on the instrument the person(s), or the
entity upon behalf of which the person(s) acted, executed the
CAPACITY CLAIMED BY SIGNER
_____ Corporate Officer
_____ Limited Partner
_____ General Partner
WITNESS my hand and official seal.