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North Carolina ________ as identification. _________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -5- was acknowledged before me this _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally known to me or who has produced _____________________________________________ City: __________________________________ State: ___________________________________ State of NORTH CAROLINA ) ) ss County of ________________________ ) The foregoing instrumentame: ___________________________________ City: __________________________________ State: ___________________________________ Witness Signature: ___________________________________ Name: ______________. Signed on ________________ (date), at _______________________ (city), North Carolina. ________________________________ Signature of Principal Witness Signature: ___________________________________ Nlure to act in good faith and/or willful misconduct, while acting under the authority of this Power of Attorney. I may revoke this Power of Attorney at any time by providing written notice to my Agent such termination, shall be held harmless. -4- Agent shall not be liable for losses resulting from judgment errors made in good faith. However, Agent will be liable for breach of fiduciary duty, faiecause of reliance on this power of attorney. If this Durable Power of Attorney is terminated by operation of law, any person relying in good faith on the authority of this document, without notice of 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 any claims that arise against the third party bn the life of my Agent; and/or (c) my assets to be subject to a general power of appointment by my Agent. Any third party who receives a copy of this document may act under it. Revocation of the powerof-attorney are limited to the extent necessary to prevent (a) my income to be taxable to my Agent; (b) my Agent to have any rights or ownership with respect to any life insurance policies I may own oquire as to the reasons for the use or issuance of this power-ofattorney or as to the disposition of any proceeds paid to my Agent based on this document. The powers granted to my Agent by this power-unenforceable under applicable law, then the remaining unaffected parts of the document shall still remain in full force and effect and not be affected by any partial invalidity. No person needs to inific terms, rights, acts or powers are not intended to restrict or limit the definition or scope of powers granted herein in any manner. If any part of this document is held to be invalid, illegal or my Agent shall provide an accounting for all funds handled and all acts performed as my Agent. This Power of Attorney shall be construed as broadly as a General Power of Attorney. The listing of spec, my Agent shall also be entitled to reasonable compensation for any services provided as my Agent If so requested by myself or any authorized personal representative or fiduciary acting on my behalf,inancial resources and affairs properly. My Agent shall be entitled to reimbursement of all reasonable expenses incurred as a result of carrying out any provision of this Power of Attorney. If desired by any applicable statute). As used herein, "disability" or "incapacity" shall mean a lack of capacity to receive and evaluate information effectively, to communicate decisions, and/or to manage my fall remain in full force and effect thereafter until my death. -3- This Power of Attorney shall not terminate on my subsequent disability, incapacity or lack of mental competence (except as provided Durable Power of Attorney and the rights, powers, and authority of my Agent shall become effective immediately upon execution of this instrument. The rights, powers, and authority of this document shmay be appropriate. However, Agent may not disclaim assets, to which I would be entitled, if the result is that the disclaimed assets pass directly or indirectly to my Agent or my Agent's estate. Thisf such transfer. 17. To disclaim any interest (subject to other provisions of this document), which might be transferred or distributed to me from any other person, estate, trust, or other entity, as gent may owe to others, excluding those whom I am legally obligated to support. 16. To transfer any of my assets to the trustee of any revocable trust created by me, if such trust exists at the time oent's estate, my Agent's creditors, or the creditors of my Agent's estate, or (c) use any of my assets to discharge any of my Agent's legal obligations, including any obligations of support which my Aghts, directly or indirectly, to my Agent, my Agent's estate, my Agent's creditors, or the creditors of my Agent's estate, (b) exercise any powers of appointment I may hold in favor of my Agent, my Age and shall lapse at the end of each calendar year. However, my Agent may not, unless specifically authorized by this document, (a) gift, appoint, assign or designate any of my assets, interests or rits that qualify for the federal gift tax annual exclusion, shall not exceed in value the federal gift tax annual exclusion amount in any one calendar year, and this annual right shall be non-cumulativade to the minor directly or parent, guardian or close friend of the minor or pursuant to the Uniform Gifts to Minors Act or the Uniform Transfers To Minors Act. Any gifts made shall be limited to gifganizations without regard to whether such gifts are a part of my estate planning or otherwise, and if necessary, to file any state and federal gift tax returns and documents. Gifts to minors may be m matters and to negotiate, compromise or settle any matter with such agency. 15. To make gifts and charitable contributions of my real, personal, tangible or intangible property, to such persons or or federal, state, local or other income and tax returns and necessary and/or related documents; to obtain or provide information to and from any agency, including governmental agencies, relating to taxnals, brokers and real estate agents. 14. To prepare, or cause to be prepared, sign, and/or file any documents with any federal, state, local or other governmental body, including, but not limited to,y own or have an interest in, in the future. 13. To employ any professional and/or business assistance as may be appropriate, including but not limited to, attorneys, accountants, investment professioxy rights, with respect to stocks, bonds, debentures, commodities, options or any other investments. -2- 12. To maintain and/or operate any business that I currently own or have an interest in or ma alone or in conjunction with any other person, including access to their contents, and to examine, remove, keep or otherwise dispose of the contents. 11. To exercise any and all rights, including protransfer any note, security, or draft of the United States of America, including U.S. Treasury Securities. 10. To have access to any safe deposit box, vault or other storage area owned or leased by me warrants, money orders, certificates, cashier checks, cash or vouchers payable to me by any person, firm, corporation or political entity; to perform any act necessary to deposit, negotiate, sell or h respect to any of my accounts, including, but not limited to, making deposits and withdrawals, negotiating or endorsing any checks or other instruments, obtaining bank statements, passbooks, drafts,eposit, investment accounts, brokerage accounts, retirement plan accounts, and other similar accounts with financial institutions; to conduct any business with any banking or financial institution witive Payee" for the purpose of receiving Social Security benefits. 9. To open, maintain and/or close bank accounts, including, but not limited to, checking accounts, savings accounts, certificates of ds agencies in connection with governmental benefits (including but not limited to, medical, military and social security benefits), and to appoint anyone, including my Agent, to act as my "Representatefits and government program including, but not limited to, Social Security and Medicare; to prepare applications, provide information, and perform any other reasonable request by any government or itaimers under such policies. 8. To receive, deposit, hold, demand, deal with and/or sue to recover all payments I receive from any annuity, pension, retirement benefits, retirement plans, insurance bense, maintain and/or deal with insurance and annuity contracts, insurance policies, including life insurance upon my life or the life of any other appropriate person and to make any elections and disclnd to recover possession; and the right to ask for, demand, sue for, collect, recover and receive all monies which may become due and owing to me by reason of such transaction. 7. To apply for, purchaecute any necessary document, instrument or deed for such transactions. This includes the right to sell or encumber any homestead that I now own or may own in the future; the right to remove tenants aces my Agent may deem proper) deal with all, any part or any interest in any real or personal property or asset whatsoever, tangible or intangible (now owned or acquired in the future by me) and to exeafter acquire any interest, to have, or use. 6. To maintain, manage, insure, lease, rent, sell, mortgage, improve, repair, exchange, invest, reinvest and in any other manner (on such terms and at priny and all documents of title and demands whatsoever, whether agreed to or disputed, now due or due -1- in the future, owned by, due, owing payable, or belonging to, me or in which I have or may herossess and/or invest any and all sums of money, accounts, debts, bonds, commercial papers, checks, drafts, causes of action, bequests, deposits, notes, interests, dividends, certificates of deposit, asary to recover and collect any amount or debt owed to me. 4. To adjust, compromise and settle any claim, against me or asserted on my behalf against any other person or entity. 5. To receive, hold, p security agreements and other debts and obligations and such other instruments in writing of whatever kind and nature as may be. 3. To request, ask, demand, sue and take any and all legal steps necesinvestments with or through banks, savings and loan, brokers, mutual fund companies or other institutions, proofs of loss, evidences of debts, releases, and satisfaction of mortgages, lien, judgments,nsurance policies, receipts, title documents, checks, drafts, letters of credit, stock certificates, proxies, warrants, commercial papers, withdrawal and deposit slips, certificates of deposit of, or including but not limited to applications, assignments, bills of sale or lading, bonds, contracts, covenants, conveyances, deeds, options, trust deeds, security agreements, leases, mortgages, notes, i behalf and in my name. 2. To enter into binding contracts on my behalf and to sign, endorse and execute any written agreement and document necessary to enter into any such contract and/or agreement, nd the rights hereby granted. My Agent's powers and authority shall include, but not be limited to: 1. To conduct, engage in, and transact any and all lawful business of whatever kind or nature, on mycould do if personally present. I hereby ratify and confirm all acts that my Agent, or my Agent's substitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney aer that I now have or may later acquire in connection with or relating to any person, item, transaction, thing, business, property, real or personal, tangible or intangible, or matter whatsoever as I __________ my true and lawful attorney-in-fact for me and in my name, and in my behalf. My Agent shall have full power and authority to perform any act, power, duty, legal right or obligation whatsoev at _______________________________________________ do hereby make and appoint ________________________________________ ("Agent") maintaining an address at: ___________________________________________ities of an agent. -3- NORTH CAROLINA DURABLE POWER OF ATTORNEY Effective Immediately KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principal") maintaining an addressre decisions for you. You may revoke this power of attorney if you later wish to do so. AGENT: By accepting or acting under the appointment, the agent assumes the fiduciary and other legal responsibilattorney document, is legally binding upon you. If you have any questions about these powers, obtain competent legal advice. This document does not authorize anyone to make medical and other health-cawer to handle business and legal matters on your behalf, including the power to sell, mortgage or dispose of your property. Any such action undertaken by your agent, within the scope of this power of Powers granted by this power of attorney document are broad and sweeping. Before signing this document, consider its consequences. You ("principal") are providing another person ("agent") with the poation that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. -2- CAUTION! PRINCIPAL: Theney be witnessed, it is always a very good idea to do so. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general informge the validity of the Power of Attorney and will allow the Durable Power of Attorney to be recorded as a public record, if necessary. Although, some states don't require that a Durable Power of Attoruld always be notarized, even if your state does not require it, especially if the Agent will be dealing with any real property. Notarization will make it more difficult for any third party to challenthe Agent, within the scope of the Power of Attorney document, will be legally binding upon the Grantor. The Grantor can revoke a Durable Power of Attorney at any time. A Durable Power of Attorney shoe appointed an Attorney-In-Fact by a power of attorney. The Agent should be a competent adult. A Power of Attorney is a "powerful" instrument and should be granted with care. Any action undertaken by er becomes incapacitated. Note that the word "attorney" is not used here to mean "lawyer". The person acting as the Attorney-In-Fact for the Principal does not need to be a lawyer. Almost anyone can bs or her behalf, even if the Principal later becomes incapacitated. This particular Form becomes effective immediately and remains in full force and effect even if the Principal (i.e. the Grantor) latediately A Durable Power of Attorney allows a natural "mentally" competent person (called the "Principal" or "Grantor") to authorize someone else (called the "Agent" or "Attorney-InFact") to act on hicument with another party. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com. -1- Information Durable Power of Attorney Effective Immtitute for legal advice. These forms should only be a starting point for you and should not be used without consulting with an attorney first. An Attorney should be consulted before negotiating any dont, the Power of Attorney must be filed with the office of registrar of deeds to be valid. Filing, is not necessary if Principal is not incompetent. [_] These forms are not intended and are not a subsgent. The powers granted by this document are very broad and sweeping, as the Agent has the power to handle business and legal matters on the Principal's behalf. [_] If the Principal becomes incompete needed. [_] The Principal should be careful in instructing the Agent (or attorney-in-fact) as to the tasks the Agent should complete. The Grantor should also be very careful in the selection of the Athe Agent's spouse or children, and the Notary should not be witnesses. [_] The Principal should keep the original document, as well as a copy. The Agent should have access to the original document ason will allow the Durable Power of Attorney to be recorded as a public record, if necessary. [_] Two witnesses need to sign the Power of Attorney. The witnesses should be competent adults. The Agent, ive even if the Principal (i.e. the Grantor) becomes subsequently incapacitated. [_] The Principal (i.e. the person granting the power of Attorney) should sign the document before a Notary. NotarizatiInformation for Durable Power of Attorney Effective Immediately; (3) Durable Power of Attorney Effective Immediately [_] This Durable Power of Attorney becomes effective immediately and remains effectInstructions & Checklist North Carolina Durable Power of Attorney Effective Immediately [_] This package contains (1) Instructions & Checklist for Durable Power of Attorney Effective Immediately; (2) North CarolinaNorth Carolina fication. _________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -5- before me this _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally known to me or who has produced ________________________________ as identi_____ City: __________________________________ State: ___________________________________ State of NORTH CAROLINA ) ) ss County of ________________________ ) The foregoing instrument was acknowledged ________________________ City: __________________________________ State: ___________________________________ Witness Signature: ___________________________________ Name: __________________________________________ (date), at _______________________ (city), North Carolina. ________________________________ Signature of Principal Witness Signature: ___________________________________ Name: ___________ood faith and/or willful misconduct, while acting under the authority of this Power of Attorney. I may revoke this Power of Attorney at any time by providing written notice to my Agent. Signed on ____n, shall be held harmless. -4- Agent shall not be liable for losses resulting from judgment errors made in good faith. However, Agent will be liable for breach of fiduciary duty, failure to act in gce on this power of attorney. If this Durable Power of Attorney is terminated by operation of law, any person relying in good faith on the authority of this document, without notice of such terminationot effective as to a third party until the third party has actual knowledge of the revocation. I agree to indemnify the third party for any claims that arise against the third party because of relian Agent; and/or (c) my assets to be subject to a general power of appointment by my Agent. Any third party who receives a copy of this document may act under it. Revocation of the power of attorney is limited to the extent necessary to prevent (a) my income to be taxable to my Agent; (b) my Agent to have any rights or ownership with respect to any life insurance policies I may own on the life of myreasons for the use or issuance of this power-ofattorney or as to the disposition of any proceeds paid to my Agent based on this document. The powers granted to my Agent by this power-of-attorney are der applicable law, then the remaining unaffected parts of the document shall still remain in full force and effect and not be affected by any partial invalidity. No person needs to inquire as to the ts, acts or powers are not intended to restrict or limit the definition or scope of powers granted herein in any manner. If any part of this document is held to be invalid, illegal or unenforceable unprovide an accounting for all funds handled and all acts performed as my Agent. This Power of Attorney shall be construed as broadly as a General Power of Attorney. The listing of specific terms, righ also be entitled to reasonable compensation for any services provided as my Agent If so requested by myself or any authorized personal representative or fiduciary acting on my behalf, my Agent shall licensed medical doctor. My Agent shall be entitled to reimbursement of all reasonable expenses incurred as a result of carrying out any provision of this Power of Attorney. If desired, my Agent shallty" shall mean a lack of capacity to receive and evaluate information effectively, to communicate decisions, and/or to manage my financial resources and affairs properly, as certified in writing by a This Power of Attorney shall not terminate on my subsequent disability, incapacity or lack of mental competence, except as provided by any applicable statute. As used herein, "disability" or "incapaciuent disability or incapacity as certified in writing by a licensed medical doctor. The rights, powers, and authority of this document shall remain in full force and effect thereafter until my death. esult is that the disclaimed assets pass directly or indirectly to my Agent or my Agent's estate. This Durable Power of Attorney and all rights and powers therein shall become effective upon my subseqt be transferred or distributed to me from any other person, estate, trust, or other entity, as may be appropriate. However, Agent may not disclaim assets, to -3- which I would be entitled, if the ry assets to the trustee of any revocable trust created by me, if such trust exists at the time of such transfer. 17. To disclaim any interest (subject to other provisions of this document), which migho discharge any of my Agent's legal obligations, including any obligations of support which my Agent may owe to others, excluding those whom I am legally obligated to support. 16. To transfer any of mmy Agent's estate, (b) exercise any powers of appointment I may hold in favor of my Agent, my Agent's estate, my Agent's creditors, or the creditors of my Agent's estate, or (c) use any of my assets trized by this document, (a) gift, appoint, assign or designate any of my assets, interests or rights, directly or indirectly, to my Agent, my Agent's estate, my Agent's creditors, or the creditors of x annual exclusion amount in any one calendar year, and this annual right shall be non-cumulative and shall lapse at the end of each calendar year. However, my Agent may not, unless specifically authofts to Minors Act or the Uniform Transfers To Minors Act. Any gifts made shall be limited to gifts that qualify for the federal gift tax annual exclusion, shall not exceed in value the federal gift taecessary, to file any state and federal gift tax returns and documents. Gifts to minors may be made to the minor directly or parent, guardian or close friend of the minor or pursuant to the Uniform Gitable contributions of my real, personal, tangible or intangible property, to such persons or organizations without regard to whether such gifts are a part of my estate planning or otherwise, and if n or provide information to and from any agency, including governmental agencies, relating to tax matters and to negotiate, compromise or settle any matter with such agency. 15. To make gifts and chariuments with any federal, state, local or other governmental body, including, but not limited to, federal, state, local or other income and tax returns and necessary and/or related documents; to obtains may be appropriate, including but not limited to, attorneys, accountants, investment professionals, brokers and real estate agents. 14. To prepare, or cause to be prepared, sign, and/or file any docs. 12. To maintain and/or operate any business that I currently own or have an interest in or may own or have an interest in, in the future. 13. To employ any professional and/or business assistance a, remove, keep or otherwise dispose of the contents. 11. To exercise any and all rights, including proxy rights, with respect to stocks, bonds, debentures, commodities, options or any other investments. -2- 10. To have access to any safe deposit box, vault or other storage area owned or leased by me alone or in conjunction with any other person, including access to their contents, and to examinem, corporation or political entity; to perform any act necessary to deposit, negotiate, sell or transfer any note, security, or draft of the United States of America, including U.S. Treasury Securitieting or endorsing any checks or other instruments, obtaining bank statements, passbooks, drafts, warrants, money orders, certificates, cashier checks, cash or vouchers payable to me by any person, firth financial institutions; to conduct any business with any banking or financial institution with respect to any of my accounts, including, but not limited to, making deposits and withdrawals, negotia accounts, including, but not limited to, checking accounts, savings accounts, certificates of deposit, investment accounts, brokerage accounts, retirement plan accounts, and other similar accounts wi social security benefits), and to appoint anyone, including my Agent, to act as my "Representative Payee" for the purpose of receiving Social Security benefits. 9. To open, maintain and/or close banklications, provide information, and perform any other reasonable request by any government or its agencies in connection with governmental benefits (including but not limited to, medical, military andyments I receive from any annuity, pension, retirement benefits, retirement plans, insurance benefits and government program including, but not limited to, Social Security and Medicare; to prepare appnce upon my life or the life of any other appropriate person and to make any elections and disclaimers under such policies. 8. To receive, deposit, hold, demand, deal with and/or sue to recover all panies which may become due and owing to me by reason of such transaction. 7. To apply for, purchase, maintain and/or deal with insurance and annuity contracts, insurance policies, including life insuraor encumber any homestead that I now own or may own in the future; the right to remove tenants and to recover possession; and the right to ask for, demand, sue for, collect, recover and receive all mor asset whatsoever, tangible or intangible (now owned or acquired in the future by me) and to execute any necessary document, instrument or deed for such transactions. This includes the right to sell e, improve, repair, exchange, invest, reinvest and in any other manner (on such terms and at prices my Agent may deem proper) deal with all, any part or any interest in any real or personal property oe in the future, owned by, due, owing payable, or belonging to, me or in which I have or may hereafter acquire any interest, to have, or use. 6. To maintain, manage, insure, lease, rent, sell, mortgag drafts, causes of action, bequests, deposits, notes, interests, dividends, certificates of deposit, any and all documents of title and demands whatsoever, whether agreed to or disputed, now due or du, against me or asserted on my behalf against any other person or entity. -1- 5. To receive, hold, possess and/or invest any and all sums of money, accounts, debts, bonds, commercial papers, checks,ind and nature as may be. 3. To request, ask, demand, sue and take any and all legal steps necessary to recover and collect any amount or debt owed to me. 4. To adjust, compromise and settle any claims, proofs of loss, evidences of debts, releases, and satisfaction of mortgages, lien, judgments, security agreements and other debts and obligations and such other instruments in writing of whatever kxies, warrants, commercial papers, withdrawal and deposit slips, certificates of deposit of, or investments with or through banks, savings and loan, brokers, mutual fund companies or other institutionants, conveyances, deeds, options, trust deeds, security agreements, leases, mortgages, notes, insurance policies, receipts, title documents, checks, drafts, letters of credit, stock certificates, pro any written agreement and document necessary to enter into any such contract and/or agreement, including but not limited to applications, assignments, bills of sale or lading, bonds, contracts, coveno conduct, engage in, and transact any and all lawful business of whatever kind or nature, on my behalf and in my name. 2. To enter into binding contracts on my behalf and to sign, endorse and executetute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights hereby granted. My Agent's powers and authority shall include, but not be limited to: 1. T thing, business, property, real or personal, tangible or intangible, or matter whatsoever as I could do if personally present. I hereby ratify and confirm all acts that my Agent, or my Agent's substiave full power and authority to perform any act, power, duty, legal right or obligation whatsoever that I now have or may later acquire in connection with or relating to any person, item, transaction,intaining an address at: _____________________________________________________ as my alternate or successor Agent, as necessary, to serve with the same powers, rights and discretions. My Agent shall h____________ my true and lawful attorney-in-fact for me and in my name, and in my behalf. If the above named Agent is unable to serve for any reason, I appoint _____________________________________ mass at _______________________________________________ do hereby make and appoint ________________________________________ ("Agent") maintaining an address at: _________________________________________ies of an agent. -3- NORTH CAROLINA DURABLE POWER OF ATTORNEY Effective upon Disability KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principal") maintaining an addre decisions for you. You may revoke this power of attorney if you later wish to do so. AGENT: By accepting or acting under the appointment, the agent assumes the fiduciary and other legal responsibilittorney document, is legally binding upon you. If you have any questions about these powers, obtain competent legal advice. This document does not authorize anyone to make medical and other health-carer to handle business and legal matters on your behalf, including the power to sell, mortgage or dispose of your property. Any such action undertaken by your agent, within the scope of this power of atowers granted by this power of attorney document are broad and sweeping. Before signing this document, consider its consequences. You ("principal") are providing another person ("agent") with the poweion that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. -2- CAUTION! PRINCIPAL: The Pif the Agent will deal with any real estate in Florida. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general informato be recorded as a public record, if necessary. Although, some states don't require that a Durable Power of Attorney be witnessed, it is always a very good idea to do so. Two witnesses are necessary, t will be dealing with any real property. Notarization will make it more difficult for any third party to challenge the validity of the Power of Attorney and will allow the Durable Power of Attorney the event the original Agent is unable to serve or continue to serve as the Agent. A Durable Power of Attorney should always be notarized, even if your state does not require it, especially if the Agenme. Since this Durable Power of Attorney takes effect only after the Principal becomes disabled or incompetent, an alternate Agent can be designated, at the time this Power of Attorney is signed, in t is especially important if the Principal is incapacitated when the Power of Attorney goes into effect, or the Agent undertakes the acts. The Principal can revoke a Durable Power of Attorney at any tiney is a "powerful" instrument and should be granted with care. Any action undertaken by the Agent, within the scope of the Power of Attorney document, will be legally binding upon the Principal. This to mean "lawyer". The person acting as the attorney-in-fact for the Principal does not need to be a lawyer. Almost anyone can be appointed an attorney-in-fact by a power of attorney. A Power of Attorher behalf, even if the Principal later becomes incapacitated. This particular Form becomes effective upon the disability or incapacity of the Principal. Note that the word "attorney" is not used here A Durable Power of Attorney allows a natural "mentally competent " person (called the "Principal" or "Principal") to authorize someone else (called the "Agent" or "AttorneyIn-Fact") to act on his or another party. [_] The purchase and use of these forms, is subject to the Disclaimers and Terms of Use found at findlegalforms.com -1- Information Durable Power of Attorney Effective upon Disability legal advice. These forms should only be a starting point for you and should not be used without consulting with an attorney first. An Attorney should be consulted before negotiating a document with ower of Attorney must be filed with the office of registrar of deeds to be valid. Filing is not necessary if Principal is not incompetent. [_] These forms are not intended and are not a substitute foro serve or continue to serve as the Agent. This section can be removed, deleted (and initialed) or the words "no one" can be entered. [_] In North Carolina, if the Principal becomes incompetent, the Ps the power to handle business and legal matters on the Principal's behalf. [_] This document offers the option of nominating an alternate Agent in the event that the first choice as Agent is unable tfact) as to the tasks the Agent should complete. The Grantor should also be very careful in the selection of the Agent. The powers granted by this document are very broad and sweeping, as the Agent hapal should keep the original document, as well as a copy. The Agent should have access to the original document as needed. [_] The Principal should be careful in instructing the Agent (or attorney-in-ealing with any real estate in Florida. The witnesses should be adults. Generally, anyone related by blood or marriage to the Principal, the Agent or the Notary should not be a witness. [_] The Princid as a public record, if necessary. [_] Although not always required, it is always a good idea to also have two witnesses sign the Power of Attorney. Two witnesses are necessary if the Agent will be dility of the Principal. [_] The Principal (i.e. the person granting the Power of Attorney) should sign the document before a Notary. Notarization will allow the Durable Power of Attorney to be recordety; (2) Information for Durable Power of Attorney Effective upon Disability; (3) Durable Power of Attorney Effective upon Disability [_] This Durable Power of Attorney becomes effective upon the DisabInstructions & Checklist North Carolina Durable Power of Attorney Effective upon Disability [_] This package contains (1) Instructions & Checklist for Durable Power of Attorney Effective upon Disabili North CarolinaNorth Carolina ent (Notary Public) _________________________________ Name typed, printed, or stamped -5- ___ (name of Principal), who is personally known to me or who has produced ________________________________ as identification. _________________________________ Signature of person taking acknowledgm___ State of NORTH CAROLINA ) ) ss County of ________________________ ) The foregoing instrument was acknowledged before me this _____ day of ____________________, ______ by ____________________________________________ Witness Signature: ___________________________________ Name: ___________________________________ City: __________________________________ State: ________________________________________________ Signature of Principal Witness Signature: ___________________________________ Name: ___________________________________ City: __________________________________ State: ______________torney. I may revoke this Power of Attorney at any time by providing written notice to my Agent. Signed on ________________ (date), at _______________________ (city), North Carolina. ________________ment errors made in good faith. However, Agent will be liable for breach of fiduciary duty, failure to act in good faith and/or willful misconduct, while acting under the authority of this Power of Atn of law, any person relying in good faith on the authority of this document, without notice of such termination, shall be held harmless. -4- Agent shall not be liable for losses resulting from judgation. I agree to indemnify the third party for any claims that arise against the third party because of reliance on this power of attorney. If this General Power of Attorney is terminated by operatio 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 revocy Agent to have any rights or ownership with respect to any life insurance policies I may own on the life of my Agent; and/or (c) my assets to be subject to a general power of appointment by my Agent.proceeds paid to my Agent based on this document. The powers granted to my Agent by this power-of-attorney are limited to the extent necessary to prevent (a) my income to be taxable to my Agent; (b) mn in full force and effect and not be affected by any partial invalidity. No person needs to inquire as to the reasons for the use or issuance of this power-ofattorney or as to the disposition of any s granted herein in any manner. If any part of this document is held to be invalid, illegal or unenforceable under applicable law, then the remaining unaffected parts of the document shall still remaiower of Attorney shall be construed broadly as a General Power of Attorney. The listing of specific terms, rights, acts or powers are not intended to restrict or limit the definition or scope of powerso requested by myself or any authorized personal representative or fiduciary acting on my behalf, my Agent shall provide an accounting for all funds handled and all acts performed as my Agent. This P expenses incurred as a result of carrying out any provision of this Power of Attorney. If desired, my Agent shall also be entitled to reasonable compensation for any services provided as my Agent If y to receive and evaluate information effectively, to communicate decisions, and/or to manage my financial resources and affairs properly. My Agent shall be entitled to reimbursement of all reasonablethority of this document shall remain in full force and effect thereafter until my death or until my disability or incapacity. As used herein, "disability" or "incapacity" shall mean a lack of capacitAgent's estate. This General Power of Attorney and the rights, powers, and authority of my Agent shall become effective immediately upon execution of this instrument. The rights, powers, and -3- auor other entity, as may be appropriate. However, Agent may not disclaim assets, to which I would be entitled, if the result is that the disclaimed assets pass directly or indirectly to my Agent or my exists at the time of such transfer. 17. To disclaim any interest (subject to other provisions of this document), which might be transferred or distributed to me from any other person, estate, trust, f support which my Agent may owe to others, excluding those whom I am legally obligated to support. 16. To transfer any of my assets to the trustee of any revocable trust created by me, if such trust r of my Agent, my Agent's estate, my Agent's creditors, or the creditors of my Agent's estate, or (c) use any of my assets to discharge any of my Agent's legal obligations, including any obligations oets, interests or rights, directly or indirectly, to my Agent, my Agent's estate, my Agent's creditors, or the creditors of my Agent's estate, (b) exercise any powers of appointment I may hold in favoall be non-cumulative and shall lapse at the end of each calendar year. However, my Agent may not, unless specifically authorized by this document, (a) gift, appoint, assign or designate any of my assll be limited to gifts that qualify for the federal gift tax annual exclusion, shall not exceed in value the federal gift tax annual exclusion amount in any one calendar year, and this annual right shs to minors may be made to the minor directly or parent, guardian or close friend of the minor or pursuant to the Uniform Gifts to Minors Act or the Uniform Transfers To Minors Act. Any gifts made shao such persons or organizations without regard to whether such gifts are a part of my estate planning or otherwise, and if necessary, to file any state and federal gift tax returns and documents. Gifties, relating to tax matters and to negotiate, compromise or settle any matter with such agency. 15. To make gifts and charitable contributions of my real, personal, tangible or intangible property, t but not limited to, federal, state, local or other income and tax returns and necessary and/or related documents; to obtain or provide information to and from any agency, including governmental agencinvestment professionals, brokers and real estate agents. 14. To prepare, or cause to be prepared, sign, and/or file any documents with any federal, state, local or other governmental body, including,an interest in or may own or have an interest in, in the future. 13. To employ any professional and/or business assistance as may be appropriate, including but not limited to, attorneys, accountants, ights, including proxy rights, with respect to stocks, bonds, debentures, commodities, options or any other investments. -2- 12. To maintain and/or operate any business that I currently own or have wned or leased by me alone or in conjunction with any other person, including access to their contents, and to examine, remove, keep or otherwise dispose of the contents. 11. To exercise any and all r negotiate, sell or transfer any note, security, or draft of the United States of America, including U.S. Treasury Securities. 10. To have access to any safe deposit box, vault or other storage area o, passbooks, drafts, warrants, money orders, certificates, cashier checks, cash or vouchers payable to me by any person, firm, corporation or political entity; to perform any act necessary to deposit,cial institution with respect to any of my accounts, including, but not limited to, making deposits and withdrawals, negotiating or endorsing any checks or other instruments, obtaining bank statementss, certificates of deposit, investment accounts, brokerage accounts, retirement plan accounts, and other similar accounts with financial institutions; to conduct any business with any banking or finant as my "Representative Payee" for the purpose of receiving Social Security benefits. 9. To open, maintain and/or close bank accounts, including, but not limited to, checking accounts, savings accountany government or its agencies in connection with governmental benefits (including but not limited to, medical, military and social security benefits), and to appoint anyone, including my Agent, to acplans, insurance benefits and government program including, but not limited to, Social Security and Medicare; to prepare applications, provide information, and perform any other reasonable request by elections and disclaimers under such policies. 8. To receive, deposit, hold, demand, deal with and/or sue to recover all payments I receive from any annuity, pension, retirement benefits, retirement To apply for, purchase, maintain and/or deal with insurance and annuity contracts, insurance policies, including life insurance upon my life or the life of any other appropriate person and to make any to remove tenants and to recover possession; and the right to ask for, demand, sue for, collect, recover and receive all monies which may become due and owing to me by reason of such transaction. 7. ure by me) and to execute any necessary document, instrument or deed for such transactions. This includes the right to sell or encumber any homestead that I now own or may own in the future; the rightuch terms and at prices my Agent may deem proper) deal with all, any part or any interest in any real or personal property or asset whatsoever, tangible or intangible (now owned or acquired in the futch I have or may hereafter acquire any interest, to have, or use. 6. To maintain, manage, insure, lease, rent, sell, mortgage, improve, repair, exchange, invest, reinvest and in any other manner (on sicates of deposit, any and all documents of title and demands whatsoever, whether agreed to or disputed, now due or due -1- in the future, owned by, due, owing payable, or belonging to, me or in whi To receive, hold, possess and/or invest any and all sums of money, accounts, debts, bonds, commercial papers, checks, drafts, causes of action, bequests, deposits, notes, interests, dividends, certifll legal steps necessary to recover and collect any amount or debt owed to me. 4. To adjust, compromise and settle any claim, against me or asserted on my behalf against any other person or entity. 5.es, lien, judgments, security agreements and other debts and obligations and such other instruments in writing of whatever kind and nature as may be. 3. To request, ask, demand, sue and take any and as of deposit of, or investments with or through banks, savings and loan, brokers, mutual fund companies or other institutions, proofs of loss, evidences of debts, releases, and satisfaction of mortgag mortgages, notes, insurance policies, receipts, title documents, checks, drafts, letters of credit, stock certificates, proxies, warrants, commercial papers, withdrawal and deposit slips, certificatet and/or agreement, including but not limited to applications, assignments, bills of sale or lading, bonds, contracts, covenants, conveyances, deeds, options, trust deeds, security agreements, leases,ind or nature, on my behalf and in my name. 2. To enter into binding contracts on my behalf and to sign, endorse and execute any written agreement and document necessary to enter into any such contrac power of attorney and the rights hereby granted. My Agent's powers and authority shall include, but not be limited to: 1. To conduct, engage in, and transact any and all lawful business of whatever kter whatsoever as I could do if personally present. I hereby ratify and confirm all acts that my Agent, or my Agent's substitute or substitutes, shall lawfully do or cause to be done by virtue of this obligation whatsoever that I now have or may later acquire in connection with or relating to any person, item, transaction, thing, business, property, real or personal, tangible or intangible, or mat______________________________ my true and lawful attorney-in-fact for me and in my name, and in my behalf. My Agent shall have full power and authority to perform any act, power, duty, legal right orintaining an address at _______________________________________________ do hereby make and appoint ________________________________________ ("Agent") maintaining an address at: _______________________e agent assumes the fiduciary and other legal responsibilities of an agent. -3- GENERAL POWER OF ATTORNEY KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principal") manot 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. AGENT: By accepting or acting under the appointment, thrtaken by your agent, within the scope of this power of attorney document, is legally binding upon you. If you have any questions about these powers, obtain competent legal advice. This document does pal") are providing another person ("agent") with the power to handle business and legal matters on your behalf, including the power to sell, mortgage or dispose of your property. Any such action undeate specific instructions. -2- CAUTION! PRINCIPAL: The Powers granted by this power of attorney document are broad and sweeping. Before signing this document, consider its consequences. You ("princi advice. Furthermore, this information is general information that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include stable at findlegalforms.com as well), stays in effect even if the Grantor later becomes disabled or incapacitated. Please note that this information is not intended as and is not a substitute for legalAlthough, some states don't require that a General Power of Attorney be witnessed, it is always a very good idea to do so. Another type of Power of Attorney, called a Durable Power of Attorneys (availzation will make it more difficult for any third party to challenge the validity of the Power of Attorney and will allow the General Power of Attorney to be recorded as a public record, if necessary. al Power of Attorney at any time. A General Power of Attorney should always be notarized, even if your state does not require it, especially if the Agent will be dealing with any real property. Notarirument and should be granted with care. Any action undertaken by the Agent, within the scope of the Power of Attorney document, will be legally binding upon the Grantor. The Grantor can revoke a Generr the Principal does not need to be a lawyer. Almost anyone can be appointed an Attorney-In-Fact by a power of attorney. The Agent should be a competent adult. A Power of Attorney is a "powerful" instive until the death of the Grantor or until the Grantor becomes disabled or incapacitated. Note that the word "attorney" is not used here to mean "lawyer". The person acting as the Attorney-In-Fact foled the "Principal" or "Grantor") to authorize someone else (called the "Agent" or "Attorney-InFact") to act on his or her behalf. This particular Form becomes effective immediately and remains effectrms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -1- Information General Power of Attorney A General Power of Attorney allows a natural "mentally" competent person (calpoint for you and should not be used without consulting with an attorney first. An Attorney should be consulted before negotiating any document with another party. [_] The purchase and use of these foe Agent has the power to handle business and legal matters on the Principal's behalf. [_] These forms are not intended and are not a substitute for legal advice. These forms should only be a starting torney-in-fact) as to the tasks the Agent should complete. The Grantor should also be very careful in the selection of the Agent. The powers granted by this document are very broad and sweeping, as thThe Principal should keep the original document, as well as a copy. The Agent should have access to the original document as needed. [_] The Principal should be careful in instructing the Agent (or at will be dealing with any real estate in Florida. The witnesses should be adults. Generally, anyone related by blood or marriage to the Principal, the Agent or the Notary should not be a witness. [_] be recorded as a public record, if necessary. [_] Although not always required, it is always a good idea to also have two witnesses sign the Power of Attorney. Two witnesses are necessary if the Agented. [_] The Principal (i.e. the person granting the Power of Attorney; sometimes called the Grantor) should sign the document before a Notary. Notarization will allow the General Power of Attorney to (3) General Power of Attorney [_] This General Power of Attorney becomes effective immediately and remains effective until the death of the Grantor or until the Grantor becomes disabled or incapacitatInstructions & Checklist North Carolina General Power of Attorney [_] This package contains (1) Instructions & Checklist for General Power of Attorney; (2) Information for General Power of Attorney; North CarolinaNorth Carolina _________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -4- ______________, ______ by __________________________ (name of Principal), who is personally known to me or who has produced ________________________________ as identification. ________________________________________ Name typed, printed, or stamped -3- State of NORTH CAROLINA ) ) ss County of ________________________ ) The foregoing instrument was acknowledged before me this _____ day of ______onally known to me or who has produced ________________________________ as identification. _________________________________ Signature of person taking acknowledgment (Notary Public) _________________s County of ________________________ ) The foregoing instrument was acknowledged before me this _____ day of ____________________, ______ by __________________________ (name of Principal), who is persgnature: ___________________________________ Name: ___________________________________ City: __________________________________ State: ___________________________________ State of NORTH CAROLINA ) ) sf Mother Witness Signature: ___________________________________ Name: ___________________________________ City: __________________________________ State: ___________________________________ Witness Sittorney-in-Fact. Signed on ________________ (date), at _______________________ (city), North Carolina. ________________________________ Signature of Father ________________________________ Signature oity of this document, without notice of such termination, shall be held harmless. -2- We may revoke this Power of Attorney before the expiration date at any time by providing written notice to the Aany claims that arise against the third party because of reliance on this power of attorney. If this Power of Attorney is terminated by operation of law, any person relying in good faith on the authorment 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. We agree to indemnify the third party for ble law, then the remaining unaffected parts of the document shall still remain in full force and effect and not be affected by any partial invalidity. Any third party who receives a copy of this document of all reasonable expenses incurred as a result of carrying out any provision of this Power of Attorney. If any part of this document is held to be invalid, illegal or unenforceable under applica named herein. We hereby ratify and confirm all acts by the Attorney-in-Fact done by virtue of this power of attorney and the rights hereby granted. The Attorney-in-Fact shall be entitled to reimburse________ ("expiration date"). By signing here, we indicate that we are fully informed as to the contents of this document and understand the full import of this grant of powers to the Attorney-in-Factpower to consent to the marriage of our child/children; (iii) have the power to consent to the adoption of our child/children. This power of attorney shall be in effect from _______________ to _______ Notwithstanding other provisions in this Power of Attorney, Attorney-in-Fact shall not (i) have the authority to withhold or withdraw life sustaining procedures for any child/children; (ii) have the ssary for the performance of the powers granted by this document, including but not limited to consent forms, releases, waivers, insurance documents, claims, agreements, contracts and legal documents.alth and other insurance for our child/children and to make and file any medical or other type of claim against any health or other type of insurance company. 6. Endorse and execute any documents neceon behalf of our child/children and to adjust, compromise and settle any claim, our child/children may have against any other person or entity. 5. Apply for, purchase, maintain and/or deal with any he including, but not limited to, provisions of living quarters, food, clothing, entertainment and other customary matters. -1- 4. Request, ask, demand, sue and take any and all legal steps necessary /children; allow our child/children to participate in activities and events offered by any group, organization or educational facility. 3. Maintain the customary living standard of the child/children, Determine the education of our child/children and to register and enroll our child/children in any educational programs, schools and extracurricular activities; review any school records of the childr dental care to our child/children. Health care shall include but not be limited to the administration of anesthesia, X-ray examination, performance of operations, diagnostic and other procedures. 2.sclose the contents of any medical records; execute any consent, release or waiver of liability required by medical, dental or other health authorities incident to the provision of medical, surgical oand decline any health care at any hospital or other institution; employ any physicians, dentists, nurses, or other person whose services may be needed for such health care; review and if necessary di all acts necessary or desirable for maintaining the health, education, and welfare of our above named child/children, including, but not limited to, the powers to: 1. Provide for, approve, authorize ___________ born on __________ Name: _________________________________ born on __________ The above named Attorney-in-Fact shall have the power and authority to act entirely in loco parentis and to do _________________________________ born on __________ Name: _________________________________ born on __________ Name: _________________________________ born on __________ Name: ______________________rue and lawful agent and attorney-in-fact for us and in our name, and in our behalf to act as the guardian of our minor child/children: Name: _________________________________ born on __________ Name:________________________ hereby make and appoint ________________________________________ ("Attorney-in-Fact") maintaining an address at: _____________________________________________________ as our t________________________________________ ("Father") and ______________________________________ ("Mother"), jointly referred to as "Parents" or "Principals", maintaining an address at: ________________intment, the Attorney-in-Fact assumes the fiduciary and other legal responsibilities of an agent. -3- POWER OF ATTORNEY FOR THE CARE OF CHILDREN KNOW ALL PERSONS BY THESE PRESENTS: We ______________inding upon you. If you have any questions about these powers, obtain competent legal advice. You may revoke this power of attorney at any time. ATTORNEY-IN-FACT: By accepting or acting under the appoo handle and control the care, custody, health and welfare of your child/children. Any such action undertaken by the Attorney-in-Fact, within the scope of this power of attorney document, is legally bey for the Care of Children document are broad and sweeping. Before signing this document, consider its consequences. You ("Parents") are providing another person ("Attorney-in-Fact") with the power tnever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. -2- CAUTION! PARENTS: The powers granted by this Power of Attorn good idea to do so. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general information that is not state specific. Wheation will make it more difficult for any third party to challenge the validity of the Power of Attorney. Although, some states don't require that a Power of Attorney be witnessed, it is always a very Parents can revoke the document at any time even before the expiration date. The Power of Attorney for the Care of Children should always be notarized, even if your state does not require it. Notarizalso be careful in instructing the Attorney-in-Fact as to what the Attorney-in-Fact should do. Although the Power of Attorney for the Care of Children has a beginning and an "end/expiration" date, they careful in the selection of the Attorney-in-Fact, as the powers granted by this document are very broad and sweeping and the children are being entrusted to the Attorney-in-Fact. The Parents should medical, dental or any other type of care. Medical personnel will also generally feel more comfortable dealing with an Attorney-inFact who can provide this type of document. The Parents should be verg this type of document available, the Attorney-in-Fact will be able to better deal with any types of emergency involving the children and can avoid potential problems when, for example, arranging forif the parent will be absent for a period of time. The powers granted by this instrument are very broad. Parents are basically giving temporary custody of the children to the Attorney-infact. By havinct by a power of attorney. This form allows the Attorney-in-Fact to make decisions for the children in place of the parents, including health care, education and welfare decisions. This can be useful d "attorney" is not used here to mean "lawyer". The person acting as the Attorney-in-Fact for the Parents or the children does not need to be a lawyer. Almost anyone can be appointed an Attorney-in-Fad. This document allows parents of one or more children (sometimes called the "Principals" or "Grantors") to appoint another person to act as their Attorney-in-Fact to care for their children. The woron Power of Attorney for the Care of Children Whenever it becomes necessary to allow someone else to provide for the care of your children, a Power of Attorney for the Care of Children form can be useou and should not be used without consulting with an attorney first. [_] The purchase and use of these forms, is subject to the Disclaimers and Terms of Use found at findlegalforms.com -1- Informatieeds to be valid. Filing is not necessary if Principal is not incompetent. [_] These forms are not intended and are not a substitute for legal advice. These forms should only be a starting point for yct, as the powers granted by this document are very broad and sweeping. [_] In North Carolina, if the Principal becomes incompetent, a Power of Attorney must be filed with the office of registrar of din-Fact or Notary should not be a witness. [_] The Parents should be careful giving instructions to the Attorney-in-Fact. The Parents should also be very careful in the selection of the Attorney-in-Falways required, it is always a good idea to also have two witnesses sign the Power of Attorney. The witnesses should be adults. Generally, anyone related by blood or marriage to the Parents, Attorney-nts should keep a copy of the Power of Attorney for the Care of Children document for their records. [_] At least one witness should sign the Power of Attorney for the Care of Children. Although not asign the Power of Attorney for the Care of Children document before a Notary. [_] The original Power of Attorney for the Care of Children document should be given to the Attorney-in-Fact. [_] The Pare and (3) additional useful information about Power of Attorney for the Care of Children documents. [_] Both Parents need to sign the Power of Attorney for the Care of Children. [_] The Parents should Instructions & Checklist North Carolina Power of Attorney for the Care of Children [_] This package contains a (1) Power of Attorney for the Care of Children; (2) simple instructions plus a checklist; North CarolinaNorth Carolina ar) __________________________________________________ Clerk (Assistant Clerk) of Superior Court or Notary Public (circle one as appropriate) for the County of ____________________________ 2 did not have a claim against the declarant. I further certify that I am satisfied as to the genuineness and due execution of the declaration. This the ____ day of ___________, _________.(month and yeof an attending physician or an employee of a health facility in which the declarant was a patient or an employee of a nursing home or any group-care home in which the declarant resided, and (iv) theyny will of the declarant or codicil thereto then existing or under the Intestate Succession Act as it provides at that time, and (iii) they were not a physician attending the declarant or an employee t or to the declarant's spouse, and (ii) they did not know or have a reasonable expectation that they would be entitled to any portion of the estate of the declarant upon the declarant's death under arant, sign the attached declaration, believing him to be of sound mind; and also swore that at the time they witnessed the declaration (i) they were not related within the third degree to the declaran_________________________ and __________________________________________________________ witnesses, appeared before me and swore that they witnessed ____________________________________________, decla For A Natural Death, and that he had willingly and voluntarily made and executed it as his free act and deed for the purposes expressed in it. I further certify that _________________________________at __________________________________________________________, the declarant, appeared before me and swore to me and to the witnesses in my presence that this instrument is his Declaration Of A Desirellows: Certificate I, _________________________________________, Clerk (Assistant Clerk) of Superior Court or Notary Public (circle one as appropriate) for __________________ County hereby certify th________________________ (Witness Signature) Print Name: ___________________________________ The clerk or the assistant clerk, or a notary public may, upon proper proof, certify the declaration as fo state that I do not now have any claim against the declarant. _____________________________________________ (Witness Signature) Print Name: ___________________________________ _____________________clarant's attending physician, or an employee of a health facility in which the declarant is a 1 patient or an employee of a nursing home or any group-care home where the declarant resides. I furtherhe declarant or as an heir under the Intestate Succession Act if the declarant died on this date without a will. I also state that I am not the declarant's attending physician or an employee of the dehe declarant by blood or marriage and that I do not know or have a reasonable expectation that I would be entitled to any portion of the estate of the declarant under any existing will or codicil of tant's Signature) I hereby state that the declarant, ___________________________________________________, being of sound mind signed the above declaration in my presence and that I am not related to thhold or discontinue either artificial nutrition or hydration, or both. This the ________ day of _______________, ________________ (month and year) __________________________________________ (Declarg: _________ My physician may withhold or discontinue extraordinary means only. _________ In addition to withholding or discontinuing extraordinary means if such means are necessary, physician may wit, my physician may withhold or discontinue either artificial nutrition or hydration, or both. _________ If my physician determines that I am in a persistent vegetative state, I authorize the followinhorize the following: _________ My physician may withhold or discontinue extraordinary means only. _________ In addition to withholding or discontinuing extraordinary means if such means are necessaryal nutrition or hydration, in accordance with my specifications set forth below: (Initial any of the following, as desired): _________ If my condition is determined to be terminal and incurable, I aut incurable or if I am diagnosed as being in a persistent vegetative state. I am aware and understand that this writing authorizes a physician to withhold or discontinue extraordinary means or artifici________, being of sound mind, desire that, as specified below, my life not be prolonged by extraordinary means or by artificial nutrition or hydration if my condition is determined to be terminal and of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will Declaration Of A Desire For A Natural Death I, _________________________________________________torney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local ator any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state tonessed, and proved in accordance with the provisions of this section. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability f or incorporated into a health care power of attorney form meeting the requirements of Article 3 of Chapter 32A of the General Statutes; provided, however, that the resulting form shall be signed, witerpose this section as a defense. (i) Any certificate in the form provided by this section prior to July 1, 1979, shall continue to be valid. (j) The form provided by this section may be combined withs nor shall it be considered unprofessional conduct. Any person, institution or facility against whom criminal or civil liability is asserted because of conduct in compliance with this section may intd/or the withholding or discontinuance of either artificial nutrition or hydration, or both in accordance with this section shall not be considered the cause of death for any civil or criminal purpose accordance with subsection (c) as a condition for becoming insured under any insurance contract or for receiving any medical treatment. (h) The withholding or discontinuance of extraordinary means anarations made in accordance with subsection (c) shall not constitute suicide for any purpose. Living Will Information & Instructions ­ Page 3 (g) No person shall be required to sign a declaration in revocation shall become effective only upon communication to the attending physician by the declarant or by an individual acting on behalf of the declarant. (f) The execution and consummation of declion (2) above. (e)The above declaration may be revoked by the declarant, in any manner by which he is able to communicate his intent to revoke, without regard to his mental or physical condition. Such be proved by the clerk or assistant clerk, or a notary public a. Upon proof of the handwriting of the two witnesses whose testimony is unavailable, and b. Upon compliance with paragraph c of subdivisr assistant clerk of the superior court, or a notary public as to the genuineness and due execution of the declaration. (3) If the testimony of none of the witnesses is available, such declaration may or whose testimony is otherwise unavailable, and c. Upon proof of the handwriting of the declarant, unless he signed by his mark; or upon proof of such other circumstances as will satisfy the clerk ohe testimony of the two witnesses; or (2) If the testimony of only one witness is available, then a. Upon the testimony of such witness, and b. Upon proof of the handwriting of the witness who is dead is specifically determined to meet the requirements above: (See Below) The . . . declaration may be proved by the clerk or the assistant cle rk, or a notary public in the following manner: (1) Upon teclaration; and (4) Which has been proved before a clerk or assistant clerk of superior court, or a notary public who certifies substantially as set out in subsection (d) below. (d) The following form a patient, or an employee of a nursing home or any group-care home in which the declarant resides, and (iv) do not have a claim against any portion of the estate of the declarant at the time of the d under the Intestate Succession Act as it then provides, (iii) are not the attending physician, or an employee of the attending physician, or an employee of a health facility in which the declarant is not know or have a reasonable expectation that they would be entitled to any portion of the estate of the declarant upon his death under any will of the declarant or codicil the reto then existing orn the presence of two witnesses who believe the declarant to be of sound mind and who state that they (i) are not related within the third degree to the declarant or to the declarant's spouse, (ii) dodeclarant is aware that the declaration authorizes a physician to withhold or discontinue the extraordinary means or artificial nutrition or hydration; and (3) Which has been signed by the declarant iis determined to be Living Will Information & Instructions ­ Page 2 terminal and incurable, or if the declarant is diagnosed as being in a persistent vegetative state; and (2) Which states that the 1 of Chapter 130A of the General Statutes; (1) Which expresses a desire of the declarant that extraordinary means or artificial nutrition or hydration not be used to prolong his life if his condition pon a signed, witnessed, dated and proved declaration, or a copy of that declaration obtained from the Advance Health Care Directive Registry maintained by the Secretary of State pursuant to Article 2l nutrition or hydration, as specified by the declarant, may be withheld or discontinued upon the direction and under the supervision of the attending physician. (c) The attending physician may rely utate; and (2) There is confirmation of the declarant's present condition as set out above in subdivision (b)(1) by a physician other than the attending physician; then extraordinary means or artificiadetermined by the attending physician that the declarant's present condition is a. Terminal and incurable; or b. Repealed by Session Laws 1993, c. 553, s. 28; c. Diagnosed as a persistent vegetative selow, a desire that his life not be prolonged by extraordinary means or by artificial nutrition or hydration, and the declaration has not been revoked in accordance with subsection (e); and (1) It is and, without the use of extraordinary means or artificial nutrition or hydration, will succumb to death within a short period of time. (b) If a person has declared, in accordance with subsection (c) b North Carolina; (4) "Persistent vegetative state" is a medical condition whereby in the judgment of the attending physician the patient suffers from a sustained complete loss of self-aware cognition the moment of death by sustaining, restoring, or supplanting a vital function; (3) "Physician" means any person licensed to practice medicine under Article 1 of Chapter 90 of the laws of the State ofaccordance with subsection (c); (2) "Extraordinary means" is defined as any medical procedure or intervention which in the judgment of the attending physician would serve only to postpone artificiallyts from the North Carolina Statutes relating to Living Wills. § 90-321. Right to a natural death. (a) As used in this Article the term: (1) "Declarant" means a person who has signed a declaration in ill; (2) North Carolina Living Will. This North Carolina Living Will is based on Chapter 90 Section 90-321 et. Seq. of the North Carolina Statutes. For your convenience, we have included useful excerper of attorney, and to your physician and family members.) 7 Information and Instructions North Carolina Living Will This package contains (1) Information and Instruction for North Carolina Living W________________________________ Notary Public My Commission Expires: _______________________________ (A copy of this form should be given to your health care agent and any alternate named in this pow(iv) they did not have a claim against him/her. I further certify that I am satisfied as to the genuineness and due execution of the instrument. This the __________ day of _______________, 20____. ___r, nor an employee of an attending physician, nor an employee of a health facility in which he/she was a patient, nor an employee of a nursing home or any group-care home in which he/she resided, and is/her estate upon his/her death under any will or codicil thereto then existing or under the Intestate Succession Act as it provided at that time, and (iii) they were not a physician attending him/hethe signing (i) they were not related within the third degree to him/her or his/her spouse, and (ii) they did not know nor have a reasonable expectation that they would be entitled to any portion of hefore me and swore that they witnessed _________________________ sign the attached health care power of attorney, believing him/her to be of sound mind; and also swore that at the time they witnessed luntarily made and executed it as his/her free act and deed for the purposes expressed in it. I further certify that ____________________________ and ___________________________, witnesses, appeared bhat _______________________________ appeared before me and swore to me and to the witnesses in my presence that this 6 instrument is a health care power of attorney, and that he/she willingly and vo_____________ STATE OF North Carolina COUNTY OF _______________________ CERTIFICATE I, _________________________________, a Notary Public for _________________ County, North Carolina, hereby certify tI further state that I do not nave any claim against the principal. Witness: ______________________________________ Date: __________________ Witness: ______________________________________ Date: _____ the principal's attending physician, nor an employee of the health facility in which the principal is a patient, nor an employee of a nursing home or any group care home where the principal resides. of the principal or as an heir under the Intestate Succession Act, if the principal died on this date without a will. I also state that I am not the principal's attending physician, nor an employee of attorney in my presence, and that I am not related to the principal by blood or marriage, and I would not be entitled to any portion of the estate of the principal under any existing will or codicil ________ Date _______________ (SEAL) 9. Signatures of Witnesses. I hereby state that the Principal, ____________________________________, being of sound mind, signed the foregoing health care power oflert and competent, fully informed as to the contents of this document, and understand the full import of this grant of powers to my health care agent. Signature of Principal__________________________ty is asserted because of conduct authorized by this health care power of attorney may interpose this document as a defense. 8. Signature of principal. By signing here, I indicate that I am mentally afor any civil or criminal purposes, nor shall it be considered unprofessional conduct or as lack of professional competence. Any person, institution, or facility against whom criminal or civil liabilinstitution, or facility acting in good faith in reliance on the authority of my health care agent pursuant to this health care power of attorney shall be considered suicide, nor the cause of my death of the acts or omissions of my health care agent pursuant to this document, except for willful misconduct or gross negligence. D. No act or omission of my health care agent, or of any other person, is are hereby released and forever discharged by me, my estate, my heirs, successors, and assigns and personal representatives from all liability and from all claims or demands of all kinds arising outto my health care, my health care agent shall not have any authority over my property or financial affairs. 5 C. My health care agent and my health care agent's estate, heirs, successors, and assign incur reasonable costs on my behalf incident to the exercise of these powers; provided, however, that except as shall be necessary in order to exercise the powers described in this document relating , deliver, and acknowledge any contract or other document that may be necessary, desirable, convenient, or proper in order to exercise and carry out any of the powers described in this document and toand binding upon my family, relatives, friends, and others. 7. Miscellaneous provisions. A. I revoke any prior health care power of attorney. B. My health care agent shall be entitled to sign, executere to the benefit of and bind me, my estate, my heirs, successors, assigns, and personal representatives. The authority of my health care agent pursuant to this power of attorney shall be superior to ith by my health care agent pursuant to this power of attorney are done with my consent and sha ll have the same validity and effect as if I were present and exercised the powers myself, and shall inu document may be accepted by persons as fully authorized by me and with the same force and effect as if I were personally present, competent, and acting on my own behalf. All acts performed in good fa agent. B. The powers conferred on my health care agent by this document may be exercised by my health care agent alone, and my health care agent's signature or act under the authority granted in thisthe authority of or any representations by my health care agent shall be liable to me, my estate, my heirs, successors, assigns, or personal representatives, for actions or omissions by my health care person, to serve without bond or security. The guardian shall act consistently with G.S. 35A-1201(a)(5). 6. Reliance of third parties on health care agent. A. No person who relies in good faith upon _________________ 5. Guardianship provision. If it becomes necessary for a court to appoint a guardian of my person, I nominate my health care agent acting under this document to be the guardian of my_______________________________________________________________________ ________________________________________________________________________ _______________________________________________________advance instruction, you should indicate here whether you have executed an advance instruction for mental health treatment.): ________________________________________________________________________ _ing or capacity to make or communicate mental health treatment decisions. Because your health care agent's decisions about decisions must be consistent with any 4 statements you have expressed in an accordance with Part 2 of Article 3 of Chapter 122C of the General Statutes, which you may use to state your instructions regarding mental health treatment in the event you lack sufficient understand_____________________________________________________ C. (Notice: This health care power of attorney may incorporate or be combined with an advance instruction for mental health treatment, executed inent that are unacceptable to you): ________________________________________________________________________ ________________________________________________________________________ ___________________ electroconvulsive treatment (ECT), instructions regarding your admission to and retention in a health care facility for mental health treatment, or instructions to refuse any specific types of treatmm appropriate such as: limiting the grant of authority to make only mental health treatment decisions, your own instructions regarding the administration or withholding of psychotropic medications and make mental health decisions on my behalf, the authority of my health care agent is subject to the following special provisions and limitations. (Here you may include any specific limitations you dee____________________ ________________________________________________________________________ ________________________________________________________________________ B. In exercising the authority toith your religious beliefs, or unacceptable to you for any other reason.): ________________________________________________________________________ ____________________________________________________ou deem appropriate such as: your own definition of when life-sustaining treatment should be withheld or discontinued, or instructions to refuse any specific types of treatment that are inconsistent wority to make health care decisions on my behalf, the authority of my health care agent is subject to the fo llowing special provisions and limitations (Here you may include any specific limitations yny decisions you could make to obtain or terminate any type of health care. If you wish to limit the scope of your health care agent's powers, you may do so in this section.) A. In exercising the authility to medical providers. 4. Special provisions and limitations. (Notice: The above grant of power is intended to be as broad as possible so that your health care agent will have authority to make a, to authorize an autopsy, and to direct the disposition of my remains. 3 I. To take any lawful actions that may be necessary to carry out these decisions, including the granting of releases of liab COMA, SUFFER SEVERE DEMENTIA, OR AM IN A PERSISTENT VEGETATIVE STATE. H. To exercise any right I may have to make a disposition of any part or all of my body for medical purposes, to donate my organs-sustaining procedures do not include care necessary to provide comfort or alleviate pain. I DESIRE THAT MY LIFE NOT BE PROLONGED BY LIFE-SUSTAINING PROCEDURES IF I AM TERMINALLY ILL, PERMANENTLY IN A and may include mechanical ventilation, dialysis, antibiotics, artificial nutrition and hydration, and other forms of medical treatment which sustain, restore or supplant vital bodily functions. Lifemanently in a coma, suffer severe dementia, or am in a persistent vegetative state. Life-sustaining procedures are those forms of medical care that only serve to artificially prolong the dying processludes the power to consent to measures for relief of pain. G. To authorize the withholding or withdrawal of life-sustaining procedures when and if my physician determines that I am terminally ill, perhesia, medication, surgery, and all other diagnostic and treatment procedures ordered by or under the authorization of a licensed physician, dentist, or podiatrist. This authorization specifically incs for mental health treatment and electroconvulsive treatment (ECT) commonly referred to as "shock treatment". F. To give consent for, to withdraw consent for, or to withhold consent for, X ray, anesther institution. D. To consent to and authorize my admission to and retention in a facility for the care or treatment of mental illness. E. To consent to and authorize the administration of medicationhe disclosure of this information. B. To employ or discharge my health care providers. C. To consent to and authorize my admission to and discharge from a hospital, nursing or convalescent home, or otllowing: A. To request, review, and receive any information, verbal or written, regarding my physical or mental health, including, but not limited to, medical and hospital records, and to consent to tereby grant to my health care agent named above full power and authority to make health care decisions, including mental health treatment decisions, on my behalf, including, but not limited to, the fo_____________________________________ 2 ________________________________________________________________________ 3. General statement of authority granted. Except as indicated in section 4 below, I hcomes effective.): ________________________________________________________________________ ________________________________________________________________________ ___________________________________ligible psychologist. You may also name two or more physicians or eligible psychologists, if desired, both of whom must make this determination before the authority granted to the health care agent bee made by the following physician or eligible psychologist. (You may include here a designation of your choice, including your attending physician or eligible psychologist, or any other physician or e in effect during my incapacity, until my death. This determination shall be made by the following physician or physicians. For decisions related to mental health treatment, this determination shall bective when and if the physician or physicians designated below determine that I lack sufficient understanding or capacity to make or communicate decisions relating to my health care and will continueny manner by which you are able to communicate your intent to revoke to your health care agent and your attending physician.) Absent revocation, the authority granted in this document shall become effested with the same power and duties as if originally named as my health care agent. 2. Effectiveness of appointment. (Notice: This health care power of attorney may be revoked by you at any time in a___________________________________________________________ Home Telephone Number ____________________ Work Telephone Number ____________________ Each successor health care agent designated shall be v________________________ Home Telephone Number _____________________ Work Telephone Number _____________________ B. Name: _______________________________________________________________ Home Address: and successively, in the order named), to serve in that capacity: (Optional) A. Name: _______________________________________________________________ Home Address: ___________________________________ized in this document. 1 If the person named as my health care agent is not reasonably available or is unable or unwilling to act as my agent, then I appoint the following persons (each to act alone______ as my health care attorney- in-fact (herein referred to as my "health care agent") to act for me and in my name (in any way I could act in person) to make health care decisions for me as author_______________________________________________ Home Address: ______________________________________________________________ Home Telephone Number __________________ Work Telephone Number ____________health care that meets the statutory requirements.) 1. Designation of health care agent. I, __________________________________________, being of sound mind, hereby appoint Name: ______________________se of this form is an optional and nonexclusive method for creating a health care power of attorney and North Carolina law does not bar the use of any other or different form of power of attorney for and other health care decisions with your health care agent. Use of this form in the creation of a health care power of attorney is lawful and is authorized pursuant to North Carolina law. However, ud act if you were making the decision. Because the powers granted by this document are broad and sweeping, you should discuss your wishes concerning lifesustaining procedures, mental health treatment,care to act in your best interests and in accordance with this document. For mental health treatment decisions, your health care agent will act according to how the health care agent believes you woul are unable to give informed consent. This form does not impose a duty on your health care agent to exercise granted powers, but when a power is exercised, your health care agent will have to use due nt or stopping treatment necessary to keep you alive, admit you to a facility, and administer certain treatments and medications. This power exists only as to those health care decisions for which your you. Except to the extent that you express specific limitations or restrictions on the authority of your health care agent, this power includes the power to consent to your doctor not giving treatmeney Statutory Form, G.S. 32A-25 (Notice: This document gives the person you designate your health care agent broad powers to make health care decisions, including mental health treatment decisions, foould be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com North Carolina Health Care Power of Attormake sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document shal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legwn as an Advance Health Care Directive. The first form is the Power of Attorney for Health Care and the second form is the Living Will. [_] These forms are provided "as is" and no implied or express North Carolina Advance Health Care Directive This package contains both a North Carolina Power of Attorney for Health Care and a North Carolina Living Will. Together these forms are also sometimes kno North Carolina