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Home My WebLink About899198 Instructions and Form LIN00LN COUNTy CLERK GENE~L INSTRUCTIONS: U. thru ~urable Gen'e~l Power ~lX~i~e~ ~o~l~ ~ ~, to au~oHze so--ne ,o handlebar financial' affairs if you b~me unable to do so in ~e fq~r~,~r. ,... ,.. ifryou,.simply~ ... .want_. so--ne Io handle these ~ings rot you. A "Durable' General P~er of Attorney allows yoaho',aa~ al.r~pm~eB~Bve to ~ke I~ally binding decisions regarding your ~ney, propeAy, and o~er asse~. Read:~h~ ~Gbneml In(~n' to learn ~re about Ihis impo~nt docu~nt. Also, you should ch~k with your bank and other fl'~'nclal InA/l~tlons to dateline If ~ey will accept ~is form of Du~bie Gene~l Power of A~omey or if they require you to sign their own fo~. Be sure you undem~nd ~e im~nce of ~i's d~ment before you sign It. Talk to your family mambo, ~ends, and o~ers you ~st aboul your choirs. Also, it Is a g~d Idea to talk ~ a la.er before you sign any im~nt I~al d~ment, including ~is form. If you decide ~is is ~e fo~ you ~nt to use, co~lete ~e fo~. Do not sign this fo~ until your witness and a No~ Public are pmse~ to wEness the signing. ~ers are ~er ins~c~ons for you about signing ~ls fo~ on page 2. NOTICE: Be~m you sign a Durable General P~er of Afforney, you should consult a la.er. It is Impodant for you to be aware of not only the ~nefl~ but also the ~sslble d~advan~g~ of signing this document. Be sure you understand the e~ent of the ~wer you are giving your repr~entatlve over your business and financial a~lm and the ha~ your rep~entaflve could cause you if he/she us~ bad Judgment or unscrupulous about protecting your property. t. Information about me: (I am called the 'Principal') My Address: ~,~1 M, H0b$0)3 2. Selection of my Representative: (Also called an 'agent") My Age: °~0 My Date of Birth: My Telephone: I choose the following person to act as my representative AND to use my money, property, or assets as identified below only in my best interests, which means solely for my benefit and not for my representative's benefiL I do not authorize my representative to receive a commission, compensation, or fees for Ihis service unless and until I have specifically authorized and identified such matters in detail in a written contract in which I separately initial such authorizalJon, sign the document, and have lhe'documenl witnessed o¢ notarized. Name: 14011~/ ~hP_.~pS Home Telephone: Z.j'~-~ - ll q(~ Street Address: ~ql I k), HO'b~0/1 Work Telephone: Cell Telephone: h'?,0- ~)3 -/p~)qq ,3. When I want this Durable General Power of Attorney to become effective: NOTE: Initial or mark A or B below. You can make a Durable General Power of Attorney effective immediately, I or only ff and when you ere disabled or incapacitated and can no longer make your own financial decisions. 'Incapacitated' means mentally or physically impaired .so that you lack sufficient understanding or capacity to make or communicate responsible decisions about yourself. This decision might be mede by a physician, psychologist, or another health cam professional who can evaluate if you are Incapacitated. Talk {o a lawye~ who can advise you how and by whom your incapacity or disability can be determined. I DO NOT WANT This Power to be Effective Unless and Until I Become Unable or Lack Capacity to Make My Own Financial and Business Decisions: I want to allow my representative to act for me only if and when I become disabled or lack capacity to handle my own decisions. I DO WANT This Power to be Effective Immediately and to Last Even if I Become Disabled. I expressly want to allow my representative to act for me from this point on regardless of how much time passes. If I later suffer a sudden disability or incapacity, I still want this Power 1o be effective. (Con#hued on page AG 19) Developed by ~e Office of the Arizona Attorney General JANET NAPOLrFANO Go to the AG Web Site for ~uture updates of II'is form. September 14, 2001 Page I of 3 DURABLE GENERAL POWER OF A'I-FOP, NEY DURABLE GENERAL POWER OF ATTORNEY (Cont'd) 4. What I AUTHORIZE my Representative to do: My representative is authorized to make day-to-day financial and business decisions for me lo ensure that my daily quality of living continues in a manner to whic~ I; have been accustomed and/or which I am able to afford. My representative should discuss my choices with me if I am able to communicate in any manner and should explain to me any choices he/she makes, if I am able to understand. : I want my representative to complete and sign any legal, financial, or business documents that require my authorization, and to transact business and/or carry out my financial affairs on my behall. This authority Includes but is not limited to the following powers: · . To Issue and/or endorse any checks on my behalf, and to open or close accounts of any nature in my name or his/he~ name, and to make deposits to and withdrawals from my checking and savings accounts, and I~ have access to any safe deposit boxes that I might have. ~ · To complete and sign any business, financial, or legal documents, including those related to Social Security benefits, government bonds, mutual funds, certificates of deposit, annuilJes., and retirement benefits, and to file on my behaff federal and state tax returns, and documents related to Social Security, Medicare, Medicaid, and any insurance. · To. make any and all investments on my behalf. · To borrow against or request the cash surrender value of any of my li[e insurance policies and to transfer ownership of any such policies to the named beneficiaries, and to borrow money in my name and provide any documents necessary to give any lander a socudty interest. · To sell, lease, or mortgage any r~al or personal property that I own.' · To authorize any persons to provide assistance te me with the matters listed above or other matters. These include, but are not limited to, attorneys, financial advisors, real estate agents, and health cam professionals. 5. What I DO NOT AUTHOPJZE my Representative to do: Here is what I do not ~.~t,~orize my represe.,t, tattve to do with my money, property or other assets. (Write in any restrictions you want, or write In 'not applicable.') PRINCI PAL*S STATEMENTS AND OATH Instructions: This Durable General Power of Attorney must be signed and swu,f, to by you and your witness before e Notary Public and must show the Notary Public's certificate, and official seal. Your witness CANNOT be lhe person you have chosen as your representative, your representative's spouse or child, or the Notary Public. ff you are unable'to sign, someone can sign on your behalf, but it must be done in .your conscious p~esence and with your consent. I am under oath and I sign my name to this Durable General Power o! Attomey. I declare to b~e Notary Public that I sign this document as my pow~ of attorney. I sign it willingly, or I willingly directed someone else to sign i[ for me. I sign it as my free and voluntary act for lhe p~rpo.~es/ae~tal .ed in this,Du .m.ble General Power of Atlomey. I am eighteen years of age or older, of sound mind and I am urkJ.ef.~6 co.n~traint or unaue mnuence. ~ ~ Name: :~~ ' Date: ~~ ~)Y · ~ ' (Continued on page AG2~ Developed by the Office o{ lhe Arizona Attorney General JANET NAPOLFtrANO Go to the AG Web Site for future updates of this form. Page 2 of 3 sePiember 14, 2001 DURABLE GENERAL POWER OF ATTORNEY 0S9~1~S DURAP, LE 6ENERAL POWER OF ATTORNEY (Last Page} :--. 877 WITNESSES" STATEMENTS AND OATH I am u r~der oath and I sign my name to this Durable General Power of Attorney as the witness. I declare to the Notary Public that the person whose Durabl~. General Power o! Attorney this is (Principal) signed this documenl as his/her power of attorney. -He/she signed it willingly., or willingly directed another to sign for him/her. I, in the presence and headng of the Principal, sign this Durable General Power of Attorney as witness to the Pdncipars signing. To the best of my knowledge the Principal is eighteen year~ of.age or older, of sound mind, ana under no constraint or undue influence. I furtly!r swear that I a,rn n~c)t a child or spouse of the represenlative selected by/the Princ. ipal. ,-//- · x, NOTARY PUBLIC STATEOF ARIZONA )ss COUNTY OF /',r,,"¢'~!~",~::~ ) The undersigned, being a Notary Public certified in Arizona, declares that this Durable General Power of Attorney was subecdbed, sworn to and acknowledged before me by ~'~-,,trvz)o,M /¢'~-f , the Princip.al, and subscribed ~.~ ,orn to before me bv ~,'f¢4~ ~- ,/~7-h''A~'?z , the Witness, this _ "/_?--day of ,,~z.- '. 2'0~__~.. The person making this Durable General Power of Attorney (the Principal) appears to me to be. of sound mrna and free from duress. WITNESS MY HAND AND SEAL this ~-~y of A~,~/~ ,20 ~ ~.. No ry pub,,c: om ,s ,onexp'ras: Developed Idy the Office of the Arizona Attorney General ,^PO, ,^NO Go Io l~b Site for f~ure updates of this form. :i,::!:.~: :: ;: , September 14, 2001 Page 3 of 3- DURABLE GENERAL POWER OF A~I-ORNEY