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Pennsylvania e specified time or contingency has occurred. -6- ivorce and that, if applicable, the specified future time or contingency has occurred, is conclusive proof of the nonrevocation or nontermination of the power at that time and conclusive proof that tht he did not have at the time of exercise of the power actual knowledge of the termination of the power by revocation, death or, if applicable, disability or incapacity or the filing of an action in d___________________________ Signature of Agent _______________________________ Date -5- 20 Pa.C.S.A. Section 5606 states that an affidavit executed by the agent under a power of attorney stating tha principal separate from my assets. I shall exercise reasonable caution and prudence. I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal. ___ence of a specific provision to the contrary in the power of attorney or in 20 Pa.C.S. when I act as agent: I shall exercise the powers for the benefit of the principal. I shall keep the assets of theknowledgment by Agent I, ___________________________________, have read the attached power of attorney and am the person identified as the Agent for the Principal. I hereby acknowledge that in the abs_____________ as identification. _________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -4- Acument 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 PENNSYLVANIA ) ) ss County of ________________________ ) The foregoing instr_____ Name: ___________________________________ City: __________________________________ State: ___________________________________ Witness Signature: ___________________________________ Name: _______my Agent. Signed on ________________ (date), at _______________________ (city), Pennsylvania. ________________________________ Signature of Principal Witness Signature: ______________________________ailure to act in good faith and/or willful misconduct, while acting under the authority of this Power of Attorney. -3- I may revoke this Power of Attorney at any time by providing written notice to otice of such termination, shall be held harmless. 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, f party because 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 nhe power of attorney is not effective as to a third party until the third party has actual knowledge of the revocation. I agree to indemnify the third party for any claims that arise against the thirday own on 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 ts power-of-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 mds to inquire 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 thiegal or 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 nee of specific 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, ill behalf, 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 desired, 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 myhstanding the lapse of time since its execution. 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. Iff capacity to receive and evaluate information effectively, to communicate decisions, and/or to manage my financial resources and affairs properly. This Durable Power of Attorney shall be valid notwithall not terminate on my subsequent disability, incapacity or lack of mental competence (except as provided by any applicable statute). As used herein, "disability" or "incapacity" shall mean a lack o immediately upon execution of this instrument. The rights, powers, and authority of this document shall be exercisable notwithstanding my subsequent disability or incapacity. This Power of Attorney s" 22. "To pursue tax matters." 23. "To make an anatomical gift of all or part of my body." -2- This Durable Power of Attorney and the rights, powers, and authority of my Agent shall become effectiven insurance transactions." 18. "To engage in retirement plan transactions." 19. "To handle interests in estates and trusts." 20. "To pursue claims and litigation." 21. "To receive government benefits.s transactions." 13. "To engage in commodity and option transactions." 14. "To engage in banking and financial transactions." 15. "To borrow money." 16. "To enter safe deposit boxes." 17. "To engage i authorize medical and surgical procedures." 10. "To engage in real property transactions." 11. "To engage in tangible personal property transaction." 12. "To engage in stock, bond and other securitiesitions." "To withdraw and receive the income or corpus of a trust." "To authorize my admission to a medical, nursing, residential or similar facility and to enter into agreements for my care." 9. "Toy benefit." "To make additions to an existing trust for my benefit." "To claim an elective share of the estate of my deceased spouse." "To disclaim any interest in property." "To renounce fiduciary poo any or all of the following, each of which is defined in 20 Pa.C.S.A.5603 (relating to implementation of power of attorney): 1. 2. 3. 4. 5. 6. 7. 8. "To make limited gifts." "To create a trust for mAgent's substitute 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 empower him (her) to d, transaction, 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 shall have 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_____________________________ ("Agent") maintaining an address at: _____________________________________________________ my true and lawful attorney-in-fact for me and in my name, and in my behalf. MyOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principal") maintaining an address at _______________________________________________ do hereby make and appoint ___________AND I UNDERSTAND ITS CONTENTS. _________________________________ Signature of Principal / Grantor _________________________________ Name of Principal / Grantor __________________________ Date -1- KNN 20 PA.C.S. CH. 56. IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE YOUR AGEN'TS FUNDS. A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS NOT ACTING PROPERLY. THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE EXPLAINED MORE FULLY ID, UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY. YOUR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM GENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME INCAPACITATEEAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR A/ GRANTOR: THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE POWERS TO SELL OR OTHERWISE DISPOSE OF ANY Rg or acting under the appointment, the agent assumes the fiduciary and other legal responsibilities of an agent. -4- PENNSYLVANIA DURABLE POWER OF ATTORNEY Effective Immediately NOTICE TO PRINCIPAL tent legal advice. This document does not authorize anyone to make medical and other health-care decisions for you. You may revoke this power of attorney if you later wish to do so. AGENT: By acceptinof your property. Any such action undertaken 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 compeonsider its consequences. You ("principal") 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 offered for sale, generally include state specific instructions. -3- CAUTION! PRINCIPAL: The Powers granted by this power of attorney document are broad and sweeping. Before signing this document, cd as and is not a substitute for legal advice. Furthermore, this information is general information that is not state specific. Whenever appropriate, the instructions included with the forms packages 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. Please note that this information is not intendeith 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 to be recorded as a he Grantor can revoke a Durable Power of Attorney at any time. A Durable Power of Attorney should always be notarized, even if your state does not require it, especially if the Agent will be dealing wAttorney 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 Grantor. Tng 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. The Agent should be a competent adult. A Power of immediately and remains in full force and effect even if the Principal (i.e. the Grantor) later becomes incapacitated. Note that the word "attorney" is not used here to mean "lawyer". The person actior "Grantor") to authorize someone else (called the "Agent" or "Attorney-InFact") to act on his or her behalf, even if the Principal later becomes incapacitated. This particular Form becomes effective of Use found at findlegalforms.com. -2- Information Durable Power of Attorney Effective Immediately A Durable Power of Attorney allows a natural "mentally" competent person (called the "Principal" ulting with -1- an attorney first. An Attorney should be consulted before negotiating any document with another party. [_] The purchase and use of these forms is subject to the Disclaimers and Termsl 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 point for you and should not be used without conscomplete. 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 has the power to handle business and legae Agent should be prepared to make copies for different transactions he undertakes. [_] The Principal should be careful in instructing the Agent (or attorney-in-fact) as to the tasks the Agent should hould keep the original document, as well as a copy. The Agent should have access to the original document as needed. The Agent could also have an original document (i.e. with original signatures). Thnt. The Agent shall exercise reasonable caution and prudence. The Agent shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the Principal. [_] The Principal st at the bottom of the Power of Attorney document. The Agent shall exercise the powers for the benefit of the Principal. The Agent shall keep separate the assets of the Principal from those of the Agerded as a public record, if necessary. [_] The Principal must also sign the "Notice to Principal" at the beginning of the Power of Attorney document. [_] The Agent will have to sign the Acknowledgemenby blood or marriage to the Principal, Agent or Notary. Although not necessary, signing the document before a Notary is suggested. Notarization will also allow the Durable Power of Attorney to be recoom is 18 years of age or older. A witness shall not be the individual who signed the power of attorney on behalf of and at the direction of the principal. Furthermore, witnesses should not be related wer of Attorney is executed by mark (when the Principal is incapable of signing) or by another individual (at the direction of the Principal), then it shall be witnessed by two individuals, each of whe even if the Principal (i.e. the Grantor) becomes subsequently incapacitated. [_] The Principal (i.e. the person granting the power of Attorney) must be mentally competent. In Pennsylvania, if the Poformation for Durable Power of Attorney Effective Immediately; (3) Durable Power of Attorney Effective Immediately [_] This Durable Power of Attorney becomes effective immediately and remains effectivInstructions & Checklist Pennsylvania Durable Power of Attorney Effective Immediately [_] This package contains (1) Instructions & Checklist for Durable Power of Attorney Effective Immediately; (2) In PennsylvaniaPennsylvania contingency has occurred, is conclusive proof of the nonrevocation or nontermination of the power at that time and conclusive proof that the specified time or contingency has occurred. -7- knowledge of the termination of the power by revocation, death or, if applicable, disability or incapacity or the filing of an action in divorce and that, if applicable, the specified future time or _________________ Date -6- 20 Pa.C.S.A. Section 5606 states that an affidavit executed by the agent under a power of attorney stating that he did not have at the time of exercise of the power actualle caution and prudence. I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal. ______________________________ Signature of Agent ______________attorney or in 20 Pa.C.S. when I act as agent: I shall exercise the powers for the benefit of the principal. I shall keep the assets of the principal separate from my assets. I shall exercise reasonab the attached power of attorney and am the person identified as the alternate Agent for the Principal. I hereby acknowledge that in the absence of a specific provision to the contrary in the power of ehalf of the principal. ______________________________ Signature of Agent _______________________________ Date -5- Acknowledgment by Alternate Agent I, ___________________________________, have readhall keep the assets of the principal separate from my assets. I shall exercise reasonable caution and prudence. I shall keep a full and accurate record of all actions, receipts and disbursements on backnowledge that in the absence of a specific provision to the contrary in the power of attorney or in 20 Pa.C.S. when I act as agent: I shall exercise the powers for the benefit of the principal. I srinted, or stamped -4- Acknowledgment by Agent I, ___________________________________, have read the attached power of attorney and am the person identified as the Agent for the Principal. I hereby roduced ________________________________ as identification. _________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, p_____ ) The foregoing instrument was acknowledged before me this _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally known to me or who has p_______________ Name: ___________________________________ City: __________________________________ State: ___________________________________ State of PENNSYLVANIA ) ) ss County of _____________________________________________________ Name: ___________________________________ City: __________________________________ State: ___________________________________ Witness Signature: ____________________y providing written notice to my Agent. Signed on ________________ (date), at _______________________ (city), Pennsylvania. ________________________________ Signature of Principal Witness Signature: _able for breach of fiduciary duty, failure 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 bty of this document, without notice of such termination, shall be held harmless. -3- Agent shall not be liable for losses resulting from judgment errors made in good faith. However, Agent will be lis that arise against the third party because 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 authori act under it. Revocation of the power of attorney is not effective as to a third party until the third party has actual knowledge of the revocation. I agree to indemnify the third party for any claimny 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. Any third party who receives a copy of this document mayers 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) my Agent to have any rights or ownership with respect to atial 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 proceeds paid to my Agent based on this document. The powent is held to be invalid, illegal or 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 parPower of Attorney. The listing of specific 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 documtive or fiduciary acting on my behalf, 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 of this Power of Attorney. If desired, 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 representaAttorney shall be valid notwithstanding the lapse of time since its execution. My Agent shall be entitled to reimbursement of all reasonable expenses incurred as a result of carrying out any provisiond evaluate information effectively, to communicate decisions, and/or to manage my financial resources and affairs properly, as certified in writing by a licensed medical doctor. This Durable Power of y subsequent disability, incapacity or lack of mental competence, except as provided by any applicable statute. As used herein, "disability" or "incapacity" shall mean a lack of capacity to receive ans, powers, and authority of this document shall remain in full force and effect thereafter until my death or recovery from any disability or incapacity. This Power of Attorney shall not terminate on mdy." This Durable Power of Attorney and all rights and powers therein shall become effective upon my subsequent disability or incapacity as certified in writing by a licensed medical doctor. The rightnterests in estates and trusts." 20. "To pursue claims and litigation." 21. "To receive government benefits." 22. "To pursue tax matters." -2- 23. "To make an anatomical gift of all or part of my boking and financial transactions." 15. "To borrow money." 16. "To enter safe deposit boxes." 17. "To engage in insurance transactions." 18. "To engage in retirement plan transactions." 19. "To handle i11. "To engage in tangible personal property transaction." 12. "To engage in stock, bond and other securities transactions." 13. "To engage in commodity and option transactions." 14. "To engage in banion to a medical, nursing, residential or similar facility and to enter into agreements for my care." 9. "To authorize medical and surgical procedures." 10. "To engage in real property transactions." hare of the estate of my deceased spouse." "To disclaim any interest in property." "To renounce fiduciary positions." "To withdraw and receive the income or corpus of a trust." "To authorize my admisslementation of power of attorney): 1. 2. 3. 4. 5. 6. 7. 8. "To make limited gifts." "To create a trust for my benefit." "To make additions to an existing trust for my benefit." "To claim an elective sower of attorney and the rights hereby granted. My Agent's powers and authority shall empower him (her) to do any or all of the following, each of which is defined in 20 Pa.C.S.A.5603 (relating to impr 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 pbligation 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 matte as my alternate or successor Agent, as necessary, to serve with the same powers, rights and discretions. My Agent shall have full power and authority to perform any act, power, duty, legal right or o my behalf. If the above named Agent is unable to serve for any reason, I appoint _____________________________________ maintaining an address at: _____________________________________________________nt ________________________________________ ("Agent") maintaining an address at: _____________________________________________________ my true and lawful attorney-in-fact for me and in my name, and in Date -1- KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principal") maintaining an address at _______________________________________________ do hereby make and appoiE THIS NOTICE AND I UNDERSTAND ITS CONTENTS. _________________________________ Signature of Principal / Grantor _________________________________ Name of Principal / Grantor __________________________D MORE FULLY IN 20 PA.C.S. CH. 56. IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. I HAVE READ OR HAD EXPLAINED TO MSEPARATE FROM YOUR AGEN'TS FUNDS. A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS NOT ACTING PROPERLY. THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE EXPLAINEE INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY. YOUR AGENT MUST KEEP YOUR FUNDS RCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOMSPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXE TO PRINCIPAL / GRANTOR: THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE POWERS TO SELL OR OTHERWISE DIy accepting or acting under the appointment, the agent assumes the fiduciary and other legal responsibilities of an agent. -4- PENNSYLVANIA DURABLE POWER OF ATTORNEY Effective upon Disability NOTICEtain competent legal advice. This document does not authorize anyone to make medical and other health-care decisions for you. You may revoke this power of attorney if you later wish to do so. AGENT: Br dispose of your property. Any such action undertaken 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, obocument, consider its consequences. You ("principal") are providing another person ("agent") with the power to handle business and legal matters on your behalf, including the power to sell, mortgage o packages offered for sale, generally include state specific instructions. -3- CAUTION! PRINCIPAL: The Powers granted by this power of attorney document are broad and sweeping. Before signing this dot intended as and is not a substitute for legal advice. Furthermore, this information is general information that is not state specific. Whenever appropriate, the instructions included with the formsable Power of Attorney be witnessed, it is always a very good idea to do so. Two witnesses are necessary, if the Agent will deal with any real estate in Florida. Please note that this information is nrd party to challenge 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 Durwer 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. Notarization will make it more difficult for any thid or incompetent, an alternate Agent can be designated, at the time this Power of Attorney is signed, in the event the original Agent is unable to serve or continue to serve as the Agent. A Durable Poo effect, or the Agent undertakes the acts. The Principal can revoke a Durable Power of Attorney at any time. Since this Durable Power of Attorney takes effect only after the Principal becomes disablegent, within the scope of the Power of Attorney document, will be legally binding upon the Principal. This is especially important if the Principal is incapacitated when the Power of Attorney goes into be a lawyer. Almost anyone can be appointed an attorney-in-fact by a power of attorney. A Power of Attorney is a "powerful" instrument and should be granted with care. Any action undertaken by the Afective upon the disability or incapacity of the Principal. 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 tpal" or "Principal") to authorize someone else (called the "Agent" or "AttorneyIn-Fact") to act on his or her behalf, even if the Principal later becomes incapacitated. This particular Form becomes efs of Use found at findlegalforms.com -2- Information Durable Power of Attorney Effective upon Disability A Durable Power of Attorney allows a natural "mentally competent " person (called the "Princiout consulting with an attorney first. An Attorney should be consulted before negotiating a document with another party. [_] The purchase and use of these forms, is subject to the Disclaimers and Termialed) or the words "no one" can be entered. [_] These forms are not intended and are not a substitute for legal advice. These forms should only be a starting point for you and should not be used withment offers the option of nominating an alternate Agent in the event that the first choice as Agent is unable to serve or continue to serve as the Agent. This section can be removed, deleted (and init selection of the Agent. 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. -1- [_] This docutransactions he undertakes. [_] 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 Agent should have access to the original document as needed. The Agent could also have an original document (i.e. with original signatures). The Agent should be prepared to make copies for different gent at the bottom of the Power of Attorney document. The Alternate Agent will have the same powers and duties as the Agent. [_] The Principal should keep the original document, as well as a copy. Thence. The Agent shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the Principal. [_] The alternate Agent will have to sign the Acknowledgement of Alternate Aent shall exercise the powers for the benefit of the Principal. The Agent shall keep separate the assets of the Principal from those of the Agent. The Agent shall exercise reasonable caution and prudemust also sign the "Notice to Principal" at the beginning of the Power of Attorney document. [_].The Agent will have to sign the Acknowledgement at the bottom of the Power of Attorney document. The Aglthough not necessary, signing the document before a Notary is suggested. Notarization will also allow the Durable Power of Attorney to be recorded as a public record, if necessary. [_] The Principal e individual who signed the power of attorney on behalf of and at the direction of the principal. Furthermore, witnesses should not be related by blood or marriage to the Principal, Agent or Notary. As incapable of signing) or by another individual (at the direction of the Principal), then it shall be witnessed by two individuals, each of whom is 18 years of age or older. A witness shall not be thity of the Principal. [_] The Principal (i.e. the person granting the power of Attorney) must be mentally competent. In Pennsylvania, if the Power of Attorney is executed by mark (when the Principal i; (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 DisabilInstructions & Checklist Pennsylvania Durable Power of Attorney Effective upon Disability [_] This package contains (1) Instructions & Checklist for Durable Power of Attorney Effective upon Disability PennsylvaniaPennsylvania t the specified time or contingency has occurred. -6- in divorce and that, if applicable, the specified future time or contingency has occurred, is conclusive proof of the nonrevocation or nontermination of the power at that time and conclusive proof tha that he did not have at the time of exercise of the power actual knowledge of the termination of the power by revocation, death or, if applicable, disability or incapacity or the filing of an action ______________________________ Signature of Agent _______________________________ Date -5- 20 Pa.C.S.A. Section 5606 states that an affidavit executed by the agent under a power of attorney statingthe principal separate from my assets. I shall exercise reasonable caution and prudence. I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal. absence of a specific provision to the contrary in the power of attorney or in 20 Pa.C.S. when I act as agent: I shall exercise the powers for the benefit of the principal. I shall keep the assets of Acknowledgment by Agent I, ___________________________________, have read the attached power of attorney and am the person identified as the Agent for the Principal. I hereby acknowledge that in the ________________ as identification. _________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -4- strument 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 PENNSYLVANIA ) ) ss County of ________________________ ) The foregoing in______ Name: ___________________________________ City: __________________________________ State: ___________________________________ Witness Signature: ___________________________________ Name: _____my Agent. Signed on ________________ (date), at _______________________ (city), Pennsylvania. ________________________________ Signature of Principal Witness Signature: _____________________________ailure to act in good faith and/or willful misconduct, while acting under the authority of this Power of Attorney. -3- I may revoke this Power of Attorney at any time by providing written notice to otice of such termination, shall be held harmless. 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, f party because of reliance on this power of attorney. If this General Power of Attorney is terminated by operation of law, any person relying in good faith on the authority of this document, without nhe power of attorney is not effective as to a third party until the third party has actual knowledge of the revocation. I agree to indemnify the third party for any claims that arise against the thirday own on 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 ts power-of-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 mds to inquire 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 thiegal or 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 nee of specific 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, ill my behalf, my Agent shall provide an accounting for all funds handled and all acts performed as my Agent. This Power of Attorney shall be construed broadly as a General Power of Attorney. The listing If desired, 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 onmanage my financial 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.h or until my disability or incapacity. As used herein, "disability" or "incapacity" shall mean a lack of capacity to receive and evaluate information effectively, to communicate decisions, and/or to rity of my Agent shall become effective immediately upon execution of this instrument. The rights, powers, and authority of this document shall remain in full force and effect thereafter until my deat." 21. "To receive government benefits." 22. "To pursue tax matters." 23. "To make an anatomical gift of all or part of my body." -2- This General Power of Attorney and the rights, powers, and author safe deposit boxes." 17. "To engage in insurance transactions." 18. "To engage in retirement plan transactions." 19. "To handle interests in estates and trusts." 20. "To pursue claims and litigationgage in stock, bond and other securities transactions." 13. "To engage in commodity and option transactions." 14. "To engage in banking and financial transactions." 15. "To borrow money." 16. "To enteer into agreements for my care." 9. "To authorize medical and surgical procedures." 10. "To engage in real property transactions." 11. "To engage in tangible personal property transaction." 12. "To enin property." "To renounce fiduciary positions." "To withdraw and receive the income or corpus of a trust." "To authorize my admission to a medical, nursing, residential or similar facility and to entimited gifts." "To create a trust for my benefit." "To make additions to an existing trust for my benefit." "To claim an elective share of the estate of my deceased spouse." "To disclaim any interest uthority shall empower him (her) to do any or all of the following, each of which is defined in 20 Pa.C.S.A.5603 (relating to implementation of power of attorney): 1. 2. 3. 4. 5. 6. 7. 8. "To make lonfirm 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 and the rights hereby granted. My Agent's powers and a with or relating to any person, item, transaction, thing, business, property, real or personal, tangible or intangible, or matter whatsoever as I could do if personally present. I hereby ratify and c 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 whatsoever that I now have or may later acquire in connectiono hereby make and appoint ________________________________________ ("Agent") maintaining an address at: _____________________________________________________ my true and lawful attorney-in-fact for me_______________________ Date -1- KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principal") maintaining an address at _______________________________________________ dD OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS CONTENTS. _________________________________ Signature of Principal / Grantor _________________________________ Name of Principal / Grantor ___F ATTORNEY ARE EXPLAINED MORE FULLY IN 20 PA.C.S. CH. 56. IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. I HAVE REAT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR AGEN'TS FUNDS. A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS NOT ACTING PROPERLY. THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OE, EVEN AFTER YOU BECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY. YOUR AGENBUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIMTO SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS, OWER OF ATTORNEY NOTICE TO PRINCIPAL / GRANTOR: THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE POWERS 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 responsibilities of an agent. -4- PENNSYLVANIA GENERAL PIf you have any questions about these powers, obtain competent legal advice. This document does not authorize anyone to make medical and other health-care decisions for you. You may revoke this power 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 attorney document, is legally binding upon you. nt are broad and sweeping. Before signing this document, consider its consequences. You ("principal") are providing another person ("agent") with the power to handle business and legal matters on yourpriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. -3- CAUTION! PRINCIPAL: The Powers granted by this power of attorney documeacitated. 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. Whenever approood idea to do so. Another type of Power of Attorney, called a Durable Power of Attorneys (available at findlegalforms.com as well), stays in effect even if the Grantor later becomes disabled or incapy and will allow the General Power of Attorney to be recorded as a public record, if necessary. Although, some states don't require that a General Power of Attorney be witnessed, it is always a very gtate 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 challenge the validity of the Power of Attorner of Attorney document, will be legally binding upon the Grantor. The Grantor can revoke a General Power of Attorney at any time. A General Power of Attorney should always be notarized, even if your swer 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 the Agent, within the scope of the Powe 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 be appointed an Attorney-In-Fact by a po act on his or her behalf. This particular Form becomes effective immediately and remains effective until the death of the Grantor or until the Grantor becomes disabled or incapacitated. Note that the Power of Attorney A General Power of Attorney allows a natural "mentally" competent person (called the "Principal" or "Grantor") to authorize someone else (called the "Agent" or "Attorney-InFact") tod before negotiating any document with another party. -1- [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -2- Information Generalintended and are not a substitute 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 consultection of the Agent. 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. [_] These forms are not actions he undertakes. [_] 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 selet should have access to the original document as needed. The Agent could also have an original document (i.e. with original signatures). The Agent should be prepared to make copies for different trans The Agent shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the Principal. [_] The Principal should keep the original document, as well as a copy. The Agenshall exercise the powers for the benefit of the Principal. The Agent shall keep separate the assets of the Principal from those of the Agent. The Agent shall exercise reasonable caution and prudence.o Principal" at the beginning of the Power of Attorney document. [_] The Agent (i.e. Attorney in Fact) will have to sign the Acknowledgement at the bottom of the Power of Attorney document. The Agent y, signing the document before a Notary is suggested. Notarization will also allow the Power of Attorney to be recorded as a public record, if necessary. [_] The Principal must also sign the "Notice tned the power of attorney on behalf of and at the direction of the principal. Furthermore, witnesses should not be related by blood or marriage to the Principal, Agent or Notary. Although not necessarng) or by another individual (at the direction of the Principal), then it shall be witnessed by two individuals, each of whom is 18 years of age or older. A witness shall not be the individual who sig. [_] The Principal (i.e. the person granting the power of Attorney) must be mentally competent. In Pennsylvania, if the Power of Attorney is executed by mark (when the Principal is incapable of signi) 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 incapacitatedInstructions & Checklist Pennsylvania General Power of Attorney [_] This package contains (1) Instructions & Checklist for General Power of Attorney; (2) Information for General Power of Attorney; (3 PennsylvaniaPennsylvania ate -6- l and accurate record of all actions, receipts and disbursements on behalf of the principals and the child/children. ______________________________ Signature of Agent _______________________________ D of the principals and the child/children. I shall keep the assets of the principal and the child/children separate from my assets. I shall exercise reasonable caution and prudence. I shall keep a ful Principals. I hereby acknowledge that in the absence of a specific provision to the contrary in the power of attorney or in 20 Pa.C.S. when I act as agent: I shall exercise the powers for the benefit_______ Name typed, printed, or stamped -5- Acknowledgment by Agent I, ___________________________________, have read the attached power of attorney and am the person identified as the Agent for theown to me or who has produced ________________________________ as identification. _________________________________ Signature of person taking acknowledgment (Notary Public) __________________________of ________________________ ) The foregoing instrument was acknowledged before me this _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally kn________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -4- State of PENNSYLVANIA ) ) ss County his _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally known to me or who has produced ________________________________ as identification. _y: __________________________________ State: ___________________________________ State of PENNSYLVANIA ) ) ss County of ________________________ ) The foregoing instrument was acknowledged before me t_______________ City: __________________________________ State: ___________________________________ Witness Signature: ___________________________________ Name: ___________________________________ Citennsylvania. ________________________________ Signature of Father ________________________________ Signature of Mother Witness Signature: ___________________________________ Name: ____________________We may revoke this Power of Attorney before the expiration date at any time by providing written notice to the Attorney-in-Fact. Signed on ________________ (date), at _______________________ (city), Pney. If this 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 termination, shall be held harmless. -3- d party until the third party has actual knowledge of the revocation. We agree to indemnify the third party for any claims that arise against the third party because of reliance on this power of attorforce and effect and not be affected by any partial invalidity. 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 thiris Power of Attorney. 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 remain in full tue of this power of attorney and the rights hereby granted. The Attorney-in-Fact shall be entitled to reimbursement of all reasonable expenses incurred as a result of carrying out any provision of th to the contents of this document and understand the full import of this grant of powers to the Attorney-in-Fact named herein. We hereby ratify and confirm all acts by the Attorney-in-Fact done by virto the adoption of our child/children. This power of attorney shall be in effect from _______________ to _______________ ("expiration date"). By signing here, we indicate that we are fully informed as(i) have the authority to withhold or withdraw life sustaining procedures for any child/children; (ii) have the power to consent to the marriage of our child/children; (iii) have the power to consent ted to consent forms, releases, waivers, insurance documents, claims, agreements, contracts and legal documents. Notwithstanding other provisions in this Power of Attorney, Attorney-in-Fact shall not r type of claim against any health or other type of insurance company. 6. Endorse and execute any documents necessary for the performance of the powers granted by this document, including but not limidren may have against any other person or entity. -2- 5. Apply for, purchase, maintain and/or deal with any health and other insurance for our child/children and to make and file any medical or othement and other customary matters. 4. Request, ask, demand, sue and take any and all legal steps necessary on behalf of our child/children and to adjust, compromise and settle any claim, our child/chilny group, organization or educational facility. 3. Maintain the customary living standard of the child/children, including, but not limited to, provisions of living quarters, food, clothing, entertaindren in any educational programs, schools and extracurricular activities; review any school records of the child/children; allow our child/children to participate in activities and events offered by a administration of anesthesia, X-ray examination, performance of operations, diagnostic and other procedures. 2. Determine the education of our child/children and to register and enroll our child/chilability required by medical, dental or other health authorities incident to the provision of medical, surgical or dental care to our child/children. Health care shall include but not be limited to the dentists, nurses, or other person whose services may be needed for such health care; review and if necessary disclose the contents of any medical records; execute any consent, release or waiver of liur above named child/children, including, but not limited to, the powers to: 1. Provide for, approve, authorize and decline any health care at any hospital or other institution; employ any physicians,_ The above named Attorney-in-Fact shall have the power and authority to act entirely in loco parentis and to do all acts necessary or desirable for maintaining the health, education, and welfare of o_____ born on __________ Name: _________________________________ born on __________ Name: _________________________________ born on __________ Name: _________________________________ born on _________ct as the guardian of our minor child/children: Name: _________________________________ born on __________ Name: _________________________________ born on __________ Name: _____________________________ ("Attorney-in-Fact") maintaining an address at: _____________________________________________________ as our true and lawful agent and attorney-in-fact for us and in our name, and in our behalf to a______ ("Mother"), jointly referred to as "Parents" or "Principals", maintaining an address at: ________________________________________ hereby make and appoint ______________________________________________________ Date __________________________ Date -1- KNOW ALL PERSONS BY THESE PRESENTS: We ______________________________________________________ ("Father") and ____________________________________ Name of Principal / Grantor (Father) _________________________________ Signature of Principal / Grantor (Mother) _________________________________ Name of Principal / Grantor (Mother) ___________PLAIN IT TO YOU. I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS CONTENTS. _________________________________ Signature of Principal / Grantor (Father) _____________________________OF AN AGENT UNDER A POWER OF ATTORNEY ARE EXPLAINED MORE FULLY IN 20 PA.C.S. CH. 56. IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY. A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS NOT ACTING PROPERLY. THE POWERS AND DUTIES DUE CARE TO ACT FOR YOUR BENEFIT AND THE BENEFIT OF THE CHILDREN AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE UNTIL THE EXPIRATION DATE, UNTIL YOU REVOLD/CHILDREN WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USERE OF CHILDREN NOTICE TO PRINCIPALS / GRANTORS: THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE THE HEALTH, CARE AND WELFARE OF YOUR CHIat any time. ATTORNEY-IN-FACT: By accepting or acting under the appointment, the Attorney-in-Fact assumes the fiduciary and other legal responsibilities of an agent. -3- POWER OF ATTORNEY FOR THE CAt, 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. You may revoke this power of attorney ) are providing another person ("Attorney-in-Fact") with the power to handle and control the care, custody, health and welfare of your child/children. Any such action undertaken by the Attorney-in-Fac. -2- CAUTION! PARENTS: The powers granted by this Power of Attorney for the Care of Children document are broad and sweeping. Before signing this document, consider its consequences. You ("Parents"s information is general information that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructionst require that a Power of Attorney 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, thialways be notarized, even if your state does not require it. Notarization will make it more difficult for any third party to challenge the validity of the Power of Attorney. Although, some states don'e Care of Children has a beginning and an "end/expiration" date, the Parents can revoke the document at any time even before the expiration date. The Power of Attorney for the Care of Children should ren are being entrusted to the Attorney-in-Fact. The Parents should also be careful in instructing the Attorney-in-Fact as to what the Attorney-in-Fact should do. Although the Power of Attorney for thact who can provide this type of document. The Parents should be very careful in the selection of the Attorney-in-Fact, as the powers granted by this document are very broad and sweeping and the childen and can avoid potential problems when, for example, arranging for medical, dental or any other type of care. Medical personnel will also generally feel more comfortable dealing with an Attorney-inFg temporary custody of the children to the Attorney-infact. By having this type of document available, the Attorney-in-Fact will be able to better deal with any types of emergency involving the childrng health care, education and welfare decisions. This can be useful if the parent will be absent for a period of time. The powers granted by this instrument are very broad. Parents are basically givineed to be a lawyer. Almost anyone can be appointed an Attorney-in-Fact by a power of attorney. This form allows the Attorney-in-Fact to make decisions for the children in place of the parents, includito act as their Attorney-in-Fact to care for their children. The word "attorney" is not used here to mean "lawyer". The person acting as the Attorney-in-Fact for the Parents or the children does not nildren, a Power of Attorney for the Care of Children form can be used. This document allows parents of one or more children (sometimes called the "Principals" or "Grantors") to appoint another person laimers and Terms of Use found at findlegalforms.com -1- Information Power of Attorney for the Care of Children Whenever it becomes necessary to allow someone else to provide for the care of your ch for legal advice. These forms should only be a starting point for you and should not be used without consulting with an attorney first. [_] The purchase and use of these forms, is subject to the Discents should also be very careful in the selection of the Attorney-in-Fact, as the powers granted by this document are very broad and sweeping. [_] These forms are not intended and are not a substitute [_] The Parents should keep a copy of the Power of Attorney for the Care of Children document for their records. [_] The Parents should be careful giving instructions to the Attorney-in-Fact. The Par Acknowledgement at the bottom of the Power of Attorney for the Care of Children document. [_] The original Power of Attorney for the Care of Children document should be given to the Attorney-in-Fact.ennsylvania, the Principal must also sign the "Notice to Principal" at the beginning of the Power of Attorney document. [_] In Pennsylvania, the Agent (i.e. the Attorney-in-Fact) will have to sign then the presence of two witnesses (who will also have to sign the document). The witnesses must not be under 18 and should not be related by blood or marriage to the Principal, Agent or Notary. [_] In PPrincipals (i.e. the parents granting the power of Attorney) must be mentally competent and must sign the document before a Notary. [_] In Pennsylvania, the Power of Attorney also needs to be signed ind (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. [_] In Pennsylvania, the Instructions & Checklist Pennsylvania 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; a PennsylvaniaPennsylvania e Agent / Surrogate _______________________________ Date -5- asonable caution and prudence. I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal. ___________________________________ Signature of Substituter of attorney or in 20 Pa.C.S. when I act as agent: I shall exercise the powers for the benefit of the principal. I shall keep the assets of the principal separate from my assets. I shall exercise retached power of attorney and am the person identified as the Substitute Agent / Surrogate for the Principal. I hereby acknowledge that in the absence of a specific provision to the contrary in the powwer of attorney unless the agent has first executed and affixed to the power of attorney an acknowledgment in substantially the following form I, ___________________________________, have read the at______ Signature of Agent / Surrogate _______________________________ Date -4- Acknowledgment by Substitute Agent (Substitute Surrogate) An agent shall have no authority to act as agent under the porom my assets. I shall exercise reasonable caution and prudence. I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal. ________________________ovision to the contrary in the power of attorney or in 20 Pa.C.S. when I act as agent: I shall exercise the powers for the benefit of the principal. I shall keep the assets of the principal separate f___________________________, have read the attached power of attorney and am the person identified as the Agent / Surrogate for the Principal. I hereby acknowledge that in the absence of a specific prave no authority to act as agent under the power of attorney unless the agent has first executed and affixed to the power of attorney an acknowledgment in substantially the following form I, ________________ Witness's signature: ____________________________________________ Witness's address: ______________________________________________ -3- Acknowledgment by Agent (Surrogate) An agent shall hly and voluntarily signed this writing by signature or mark in my presence. Witness's signature: ____________________________________________ Witness's address: ______________________________________: ___________________________________________ Declarant's address: ____________________________________________ The declarant, or the person on behalf of and at the direction of the declarant, knowing___________________ Phone: _______________________________________________________ I made this declaration on the _________________ day of _________________. (day) (month, year) Declarant's signature Name and address of substitute surrogate (if surrogate designated above is unable to serve): Name: _______________________________________________________ Address: ___________________________________sciousness. Name: _______________________________________________________ Address: ______________________________________________________ Phone: _______________________________________________________-making: I do do not want to designate another person as my surrogate to make medical treatment decisions for me if I should be incompetent and in a terminal condition or in a state of permanent unconif I do not specifically indicate my preference regarding any of the forms of treatment listed above, I may receive that form of treatment. Other instructions (or write none): -2- Surrogate decisionon (water). I do do not want blood or blood products. I do do not want any form of surgery or invasive diagnostic tests. do not want kidney dialysis. I do I do do not want antibiotics. I realize that rms of treatment: I do do not want cardiac resuscitation. I do do not want mechanical respiration. do not want tube feeding or any other artificial or invasive form of I do nutrition (food) or hydratin, including any pain that might occur by withholding or withdrawing life-sustaining treatment. In addition, if I am in the condition described above, I feel especially strongly about the following foong the process of my dying, if I should be in a terminal condition or in a state of permanent unconsciousness. I direct that treatment be limited to measures to keep me comfortable and to relieve paittled commitment to refuse life-sustaining treatment under the circumstances indicated below. I direct my attending physician to withhold or withdraw life-sustaining treatment that serves only to prol_________________________________________________, being of sound mind, willfully and voluntarily make this declaration to be followed if I become incompetent. This declaration reflects my firm and seS. _________________________________ Signature of Principal / Grantor _________________________________ Name of Principal / Grantor __________________________ Date -1- Pennsylvania Declaration I, __E IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS CONTENTCAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS NOT ACTING PROPERLY. THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE EXPLAINED MORE FULLY IN 20 PA.C.S. CH. 56. IF THERT THE DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY. YOUR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR AGEN'TS FUNDS. A COURT T FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE POWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITwith a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com 2 Pennsylvania Declaration Notice NOTICE THE PURPOSE OF THits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed should only be a starting point for you and should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fpose 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 to state. These formsided in section 5604 (durable powers of attorney). [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purrney to act on behalf of that principal. § 5601.1. Powers of attorney presumed durable. Unless specifically provided otherwise in the power of attorney, all powers of attorney shall be durable as provrecord of all actions, receipts and disbursements on behalf of the principal. 1 (f) Definition.--As used in this chapter, the term "agent" means a person designated by a principal in a power of atto to: · Exercise the powers for the benefit of the principal. · Keep separate the assets of the principal from those of an agent. · Exercise reasonable caution and prudence. · Keep a full and accurate under a power of attorney has a fiduciary relationship with the principal. In the absence of a specific provision to the contrary in the power of attorney, the fiduciary relationship includes the duty of an agent to exercise a power under a power of attorney, the agent shall have the burden of demonstrating that the exercise of this authority is proper. e) Fiduciary relationship.--An agent acting ude the following notice in capital letters at the beginning of the power of attorney. The notice shall be signed by the principal. In the absence of a signed notice, upon a challenge to the authoritym is 18 years of age or older. A witness shall not be the individual who signed the power of attorney on behalf of and at the direction of the principal. (c) Notice.--All powers of attorney shall inclark, or by another on behalf of and at the direction of the principal. If the power of attorney is executed by mark or by another individual, then it shall be witnessed by two individuals, each of whoxpressly directs to the contrary, shall be construed in accordance with the provisions of this chapter. (b) Execution.--A power of attorney shall be signed and dated by the principal by signature or melegated to an agent, any or all of the powers referred to in section 5602(a) (relating to form of power of attorney) may lawfully be granted in writing to an agent and, unless the power of attorney e CH. 56. The following are useful excerpts from the Statutes relating to the Pennsylvania Declaration Form. § 5601. General provisions. (a) General rule.--In addition to all other powers that may be dvania Declaration Form; (2) Pennsylvania Declaration Form (Power of Attorney for Health Care / Living Will) Form. This Pennsylvania Declaration Form is based on the Pennsylvania Statutes at 20 PA.C.S.e contains (1) Information and Instruction for Pennsylvania Declaration Form (Power of Attorney for Health Care / Living Will) including excerpts from the Pennsylvania Statutes relating to the PennsylPennsylvania Declaration Form Information The Pennsylvania Declaration Form is a document which contains both a Living Will and a Power of Attorney for Health Care for use in Pennsylvania. This packag Pennsylvania