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Vermont -5- ______________________ as identification. _________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stampeding instrument 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 __________________________ ) ) ss County of ________________________ ) The forego_ Name: ___________________________________ City: __________________________________ State: ___________________________________ Witness Signature: ___________________________________ Name: ______________________ (date), at _______________________ (city), __________________________ (state). ________________________________ Signature of Principal Witness Signature: __________________________________od 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 _____, 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 goe 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 reliancAgent; 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 nimited 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 my easons 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 ler 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 rs, 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 undrovide 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, rightalso 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 ps 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, my Agent shall e 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 financial resourcein full force and effect thereafter until my death. This Power of Attorney shall not terminate on my subsequent disability, incapacity or lack of mental competence (except as provided by any applicablwer 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 shall remain e. 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. -3- This Durable Po17. 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 may be appropriatthers, 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 of such transfer. 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 Agent may owe to o 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 Agent's estate, my 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 rights, directly oror 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-cumulative and shall lapsedirectly 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 gifts that qualify fut 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 made to the minor egotiate, 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 organizations witholocal 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 tax matters and to n 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, federal, state, 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 professionals, brokers andespect 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 may own or have an unction 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 proxy rights, with r, 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 alone or in conjorders, 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 transfer any noteof my accounts, including, but not limited to, making deposits and withdrawals, negotiating or endorsing any checks or other instruments, obtaining bank statements, passbooks, drafts, warrants, money t accounts, brokerage accounts, retirement plan accounts, and other similar accounts with financial institutions; to conduct any business with any banking or financial institution with respect to any e 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 deposit, investmennection 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 "Representative Payee" for thent 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 its agencies in con 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 benefits and governmor 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 disclaimers under suchsession; 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, purchase, maintain and/ry 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 and to recover posdeem 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 execute any necessay 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 prices my Agent may nts 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 hereafter acquire anest any and all sums of money, accounts, debts, bonds, commercial papers, checks, drafts, causes of action, bequests, deposits, notes, interests, dividends, certificates of deposit, any and all documend 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, possess and/or invnts 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 necessary to recover aor 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, security agreeme, receipts, title documents, checks, drafts, letters of credit, stock certificates, proxies, warrants, commercial papers, withdrawal and deposit slips, certificates of deposit of, or investments with limited to applications, assignments, bills of sale or lading, bonds, contracts, covenants, conveyances, deeds, options, trust deeds, security agreements, leases, mortgages, notes, insurance policies 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, including but noteby 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 my behalf and in mynally 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 and the rights here 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 could do if persoe 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 whatsoever that I now hav__________________________________ do hereby make and appoint ________________________________________ ("Agent") maintaining an address at: _____________________________________________________ my truies of an agent. -3- DURABLE POWER OF ATTORNEY Effective Immediately KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principal") maintaining an address at _____________ 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 Py 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 informat 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 Attorned 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 challengee 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 shoulappointed 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 th 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 be 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) lateriately 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 his ment 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 Immedtute 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 docus 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 intended and are not a substie 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 Agent. The poweruse 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 as needed. [_] Thhe 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, the Agent's spo 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. Notarization will allow t Durable Power of Attorney Effective Immediately; (3) Durable Power of Attorney Effective Immediately [_] This Durable Power of Attorney becomes effective immediately and remains effective even if theInstructions & Checklist Durable Power of Attorney Effective Immediately [_] This package contains (1) Instructions & Checklist for Durable Power of Attorney Effective Immediately; (2) Information for VermontVermont amped -5- ____________________________ as identification. _________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stforegoing instrument 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 __________________________ ) ) ss County of ________________________ ) The ________ Name: ___________________________________ City: __________________________________ State: ___________________________________ Witness Signature: ___________________________________ Name: ____n ________________ (date), at _______________________ (city), __________________________ (state). ________________________________ Signature of Principal Witness Signature: ___________________________t 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. Signed oination, 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 acreliance 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 termey 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 because of 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 power of attorny 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 on the lifeo 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-of-attorneble 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 inquire as t, 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 unenforceashall 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 specific terms 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, my Agent by a 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 Agentcapacity" 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 writingeath. 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 "insubsequent 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 d the result 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 h might 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, ify of my 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), whicsets to 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 anrs of my 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 as authorized 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 creditoift tax 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 specificallyorm Gifts 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 gd if necessary, 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 Unif charitable 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, anobtain 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 andny documents 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 ance as 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 astments. 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 assistxamine, 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 inveurities. -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 en, firm, 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 Secegotiating 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 personts with 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, ne bank accounts, including, but not limited to, checking accounts, savings accounts, certificates of deposit, investment accounts, brokerage accounts, retirement plan accounts, and other similar accoury and 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 closre applications, 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, militaall payments 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 prepainsurance 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 monies 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 sell or 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 erty or 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 toortgage, 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 prop or due 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, mhecks, 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 claim, 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, cever kind 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 anytutions, 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 whats, proxies, 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 insti covenants, conveyances, deeds, options, trust deeds, security agreements, leases, mortgages, notes, insurance policies, receipts, title documents, checks, drafts, letters of credit, stock certificatexecute 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,: 1. To 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 esubstitute 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 toction, 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 hall 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, transa___ maintaining an address at: _____________________________________________________ as my alternate or successor Agent, as necessary, to serve with the same powers, rights and discretions. My Agent s__________________ 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 __________________________________ address at _______________________________________________ do hereby make and appoint ________________________________________ ("Agent") maintaining an address at: ___________________________________r legal responsibilities of an agent. -3- DURABLE POWER OF ATTORNEY Effective upon Disability KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principal") maintaining anand 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, the agent assumes the fiduciary and othee 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 not authorize anyone to make medical 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 undertaken by your agent, within the scopION! PRINCIPAL: The 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 ("n is general information that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. -2- CAUTesses are necessary, if 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 informatioe Power of Attorney to 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 witnspecially 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 Attorney and will allow the Durablorney is signed, in 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, eof Attorney at any time. 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 Attn the Principal. This 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 ney. 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 Power of Attorney document, will be legally binding uponey" 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 power of attort") to act on his or her 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 "attorctive upon Disability 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-Facting a document 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 Effe 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 consulted before negotiahoice as Agent is unable to serve or continue to serve as the Agent. This section can be removed, deleted (and initialed) or the words "no one" can be entered. [_] These forms are not intended and are sweeping, as the Agent has 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 cthe 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 Agent. The powers granted by this document are very broad and a witness. [_] The 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 ecord, if necessary. [_] Two witnesses need to sign the Power of Attorney. The witnesses should be competent adults. Anyone related by blood or marriage to the Principal, Agent or Notary should not beincipal. [_] 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 recorded as a public rtion 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 Disability of the PrInstructions & Checklist Durable Power of Attorney Effective upon Disability [_] This package contains (1) Instructions & Checklist for Durable Power of Attorney Effective upon Disability; (2) Informa VermontVermont ______ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -5- __________, ______ by __________________________ (name of Principal), who is personally known to me or who has produced ________________________________ as identification. ___________________________: ___________________________________ State of __________________________ ) ) ss County of ________________________ ) The foregoing instrument was acknowledged before me this _____ day of ______________________ State: ___________________________________ Witness Signature: ___________________________________ Name: ___________________________________ City: __________________________________ State_______ (state). ________________________________ Signature of Principal Witness Signature: ___________________________________ Name: ___________________________________ City: ______________________is Power of Attorney. I may revoke this Power of Attorney at any time by providing written notice to my Agent. Signed on ________________ (date), at _______________________ (city), ___________________ting from judgment 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 thed 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. -4- Agent shall not be liable for losses resule of the revocation. 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 terminatt by my Agent. 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 knowledgy Agent; (b) my 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 appointmensition of any 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 mll still remain 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 disposcope of powers 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 sha Agent. This Power 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 s my Agent If so 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 myall reasonable 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 aack of capacity 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 , and -3- authority 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 ly Agent or my Agent'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, powersstate, trust, or 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 mif such trust 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, e obligations of 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, y 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 to discharge any of my Agent's legal obligations, including any 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 my Agent's estate, (b) exercise any powers of appointment I mannual right shall 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 designategifts made shall 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 aocuments. Gifts 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 le property, to 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 drnmental agencies, 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 intangibdy, including, 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 gove accountants, investment 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 boy 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 as may be appropriate, including but not limited to, attorneys, any and all rights, 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 currentlstorage area owned 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 exercisery to deposit, 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 ank statements, 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 necessanking or financial 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 bavings accounts, certificates of deposit, investment accounts, brokerage accounts, retirement plan accounts, and other similar accounts with financial institutions; to conduct any business with any bay Agent, to act 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, sle request by any 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 ms, retirement plans, insurance benefits and government program including, but not limited to, Social Security and Medicare; to prepare applications, provide information, and perform any other reasonabnd to make any 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 benefitansaction. 7. 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 aure; the right 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 trred in the future 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 futr 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 or asset whatsoever, tangible or intangible (now owned or acqui, me or in which 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 otheidends, certificates 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 or entity. 5. 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, divtake any and all 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 personion of mortgages, 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 s, certificates 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 satisfactments, leases, mortgages, notes, insurance policies, receipts, title documents, checks, drafts, letters of credit, stock certificates, proxies, warrants, commercial papers, withdrawal and deposit slipy such contract and/or agreement, including but not limited to applications, assignments, bills of sale or lading, bonds, contracts, covenants, conveyances, deeds, options, trust deeds, security agree 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 execute any written agreement and document necessary to enter into anvirtue of this 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 businessngible, or matter 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 legal right or 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 inta____________________________________________ 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, Principal") maintaining an address at _______________________________________________ do hereby make and appoint ________________________________________ ("Agent") maintaining an address at: _________ppointment, the agent assumes the fiduciary and other legal responsibilities of an agent. -3- GENERAL POWER OF ATTORNEY KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("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 accepting or acting under the ach 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 competent legal advice. This . 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 of your property. Any sully include state specific instructions. -2- CAUTION! PRINCIPAL: The Powers granted by this power of attorney document are broad and sweeping. Before signing this document, consider its consequencestute for legal advice. Furthermore, this information is general information that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generatorneys (available 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 substiif necessary. Although, 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 Atoperty. Notarization 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, revoke a General 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 prpowerful" 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. The Grantor can ney-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 Attorney is a "remains effective 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 Attornt person (called 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 se of these forms 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" competebe a starting point 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 uweeping, as the 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 e 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 Agent. The powers granted by this document are very broad and sitnesses. [_] The 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 tha public record, if necessary. [_] Two witnesses need to sign the Power of Attorney. The witnesses should be competent adults. The Agent, the Agent's spouse or children, and the Notary should not be wncipal (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 be recorded as er 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 incapacitated. [_] The PriInstructions & Checklist General Power of Attorney [_] This package contains (1) Instructions & Checklist for General Power of Attorney; (2) Information for General Power of Attorney; (3) General Pow VermontVermont typed, printed, or stamped -4- who has produced ________________________________ as identification. _________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name_______________ ) The foregoing instrument was acknowledged before me this _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally known to me or_______ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -3- State of __________________________ ) ) ss County of _____________________, ______ by __________________________ (name of Principal), who is personally known to me or who has produced ________________________________ as identification. __________________________tate: ___________________________________ State of __________________________ ) ) ss County of ________________________ ) The foregoing instrument was acknowledged before me this _____ day of _________________________ State: ___________________________________ Witness Signature: ___________________________________ Name: ___________________________________ City: __________________________________ S______ Signature of Father ________________________________ Signature of Mother Witness Signature: ___________________________________ Name: ___________________________________ City: _________________te at any time by providing written notice to the Attorney-in-Fact. Signed on ________________ (date), at _______________________ (city), __________________________ (state). __________________________law, any person relying in good faith on the authority of this document, without notice of such termination, shall be held harmless. -2- We may revoke this Power of Attorney before the expiration daocation. We 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 Power of Attorney is terminated by operation of y. 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 rev 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 partial invaliditThe Attorney-in-Fact shall be entitled to reimbursement 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 toort 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 virtue of this power of attorney and the rights hereby granted. shall be in effect from _______________ to _______________ ("expiration date"). By signing here, we indicate that we are fully informed as to the contents of this document and understand the full impg procedures for any child/children; (ii) have the power 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 claims, agreements, contracts and legal documents. Notwithstanding other provisions in this Power of Attorney, Attorney-in-Fact shall not (i) have the authority to withhold or withdraw life sustainin company. 6. Endorse and execute any documents necessary for the performance of the powers granted by this document, including but not limited to consent forms, releases, waivers, insurance documents,ply for, purchase, maintain and/or deal with any health 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 insurancend, 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/children may have against any other person or entity. 5. Aphe customary living standard of the child/children, including, but not limited to, provisions of living quarters, food, clothing, entertainment and other customary matters. -1- 4. Request, ask, dema activities; review any school records of the child/children; allow our child/children to participate in activities and events offered by any group, organization or educational facility. 3. Maintain t of operations, diagnostic and other procedures. 2. Determine the education of our child/children and to register and enroll our child/children in any educational programs, schools and extracurriculares incident to the provision of medical, surgical or dental care to our child/children. Health care shall include but not be limited to the administration of anesthesia, X-ray examination, performanceed for such health care; review and if necessary disclose the contents of any medical records; execute any consent, release or waiver of liability required by medical, dental or other health authoriti the powers to: 1. Provide for, approve, authorize and decline any health care at any hospital or other institution; employ any physicians, dentists, nurses, or other person whose services may be needuthority to act entirely in loco parentis and to do all acts necessary or desirable for maintaining the health, education, and welfare of our above named child/children, including, but not limited to,___ born on __________ Name: _________________________________ born on __________ Name: _________________________________ born on __________ The above named Attorney-in-Fact shall have the power and a__________________________ born on __________ Name: _________________________________ born on __________ Name: _________________________________ born on __________ Name: ________________________________________________________________________ as our true 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: _______ipals", maintaining an address at: ________________________________________ hereby make and appoint ________________________________________ ("Attorney-in-Fact") maintaining an address at: ___________OW ALL PERSONS BY THESE PRESENTS: We ______________________________________________________ ("Father") and ______________________________________ ("Mother"), jointly referred to as "Parents" or "PrincRNEY-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 CARE OF CHILDREN KNpe 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 at any time. ATTOnother 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-Fact, within the scoPARENTS: 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") are providing ageneral information that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. -2- CAUTION! 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, this information is ed, 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't require that a n 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 always be notarizrusted 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 the Care of Childrede 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 children are being entpotential 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-inFact who can providy 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 children and can avoid ducation 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 giving temporary custor. 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, including health care, ettorney-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 need to be a lawyef 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 to act as their A 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 children, a Power o. 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 Disclaimers and Termsbe 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 for legal advicerelated by blood or marriage to the Parents, Attorney-in-Fact or Notary should not be a witness. [_] The Parents should be careful giving instructions to the Attorney-in-Fact. The Parents should also a copy of the Power of Attorney for the Care of Children document for their records. [_] Two witnesses need to sign the Power of Attorney. The witnesses should be competent adults. Generally, anyone 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 Parents should keeponal 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 sign the Power Instructions & Checklist 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; and (3) additi VermontVermont _______ _______________________________________________________ 18 V.S.A. § 5253. ___________________________________________________ Copies of this request have been given to: _______________________________________________________ ______________________________________________________________________________________________________ Date:__________________________________________________________ Witness:________________________________________________________ Witness:___________________________ __________________________________________________________________________________ __________________________________________________________________________________ Signed: __se to whom this will is addressed will regard themselves as morally bound by these provisions. Other directions (optional ­ or write none): ____________________________________________________________ordance with my strong convictions and beliefs. I want the wishes and directions here expressed carried out to the extent permitted by law. Insofar as they are not legally enforceable, I hope that thoo, however, ask that medication be mercifully administered to me to alleviate suffering even though this may shorten my remaining life. This statement is made after careful consideration and is in accwhich I am in a terminal state and there is no reasonable expectation of my recovery, I direct that I be allowed to die a natural death and that my life not be prolonged by extraordinary measures. I d_____________________ , can no longer take part in decisions of my own future, let this statement stand as an expression of my wishes, while I am still of sound mind. If the situation should arise in ecome responsible for my health, welfare or affairs. Death is as much a reality as birth, growth, matur ity and old age- it is the one certainty of life. If the time comes when I, ____________________ound at findlegalforms.com Terminal Care Document (Living Will) To my family, my physician, my lawyer, my clergyman. To any medical facility in whose care I happen to be. To any individual who may batters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use fshould not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning mess. [_]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 forms should only be a starting point for you and ath. [_] 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 purpose or as to their legal effect or completenegardless of the application of life-saving procedures would, within reasonable medical judgment, produce death and where application of life-sustaining procedures would only postpone the moment of desion-making process. (4) "Physician" means a medical doctor licensed to practice in the state of Vermont. (5) "Terminal state" means an incurable condition caused by injury, disease or illness which rction that no extraordinary measures be taken when the person executing said document is in a terminal state, without hope of recovery from such state and is unable to actively participate in the decit of death and where, in the judgment of the attending physician, the patient is in a terminal state. (3) "Terminal care document" means a document which, when duly executed, contains the express direr artificial means to sustain, restore, or supplant a vital function which, in the judgment of the attending physician, when applied to the patient, would serve only to artificially postpone the momenned to the patient, who has primary responsibility for the treatment and care of the patient. (2) "Extraordinary measures" means any medical procedure or intervention which utilizes mechanical or otheprovided herein. 18 V.S.A. § 5252. (Definitions) The following definitions shall be applicable in the construction of this chapter: (1) "Attending physician" means the physician selected by, or assigthe same or by causing the same to be done by some other person Living Will Information & Instructions ­ Page 2 at his direction and in his presence. A terminal care document may be revoked only as y revoke the same orally in the presence of two or more witnesses, at least one of whom shall not be a spouse or a relative as specified in 15 V.S.A. §§ 1 or 2, or by burning, tearing or obliterating ereof any claims against the estate of the person. 18 V.S.A. § 5257. (Revocation) A person who has validly executed a document consistent with the provisions of sections 5253 and 5254 of this title marson's spouse, heir, reciprocal beneficiary, attending physician or person acting under the direction or control of the attending physician or any other person who has at the time of the witnessing thn and witnesses) The document set forth in section 5253 of this title shall be executed by the person making the same in the presence of two or more subscribing witnesses, none of whom shall be the perolong his life when he is in a terminal state. The document shall only be effective in the event that the person is incapable of participating in decisions about his care. 18 V.S.A. § 5254. (Executiore document) A person of sound mind who is 18 years of age or older may execute at any time a document commonly known as a terminal care document, directing that no extraordinary measures be used to pas a fundamental right to determine whether or not life-sustaining procedures which would cause prolongation of life beyond natural limits, should be used or withdrawn. 18 V.S.A. § 5253. (Terminal cathat his physical state reaches such a point of deterioration that he is in a terminal state and there is no reasonable expectation that life can be continued with dignity and without pain. A person hS.A. § 5251. (Purpose and policy) The state of Vermont recognizes that a person as a matter of right may rationally make an election as to the extent of medical treatment he will receive in the event Terminal Care Document is based on Vermont Statutes Title 18 Chapter 111 Section 5253. For your convenience, we have included useful excerpts from the Vermont Statutes relating to Living Wills. 18 V.re Document (Living Will) This package contains (1) Information and Instruction for Vermont Terminal Care Document (a.k.a. Living Will); (2) Vermont Terminal Care Document (Living Will). This Vermont __ Date: _________________________________________ Address: ______________________________________ Print Name: ____________________________________ 3 Information and Instructions Vermont Terminal Cae that I have personally explained the nature and effect of this durable power of attorney to the principal and that the principal understands the same. Signature: ___________________________________tatement of ombudsman, hospital representative or other authorized person (to be signed only if the principal is in or is being admitted to a hospital, nursing home or residential care home): I declar__________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Sthe nature of the document and is signing it freely and voluntarily. _____________________________________________ (Witness Signature) Print Name: ___________________________________ 2 Address: ____ that the principal appears to be of sound mind and free from duress at the time the durable power of attorney for health care is signed and that the principal has affirmed that he or she is aware of ___________________________ In witness whereof, I have hereunto signed my name this ________. day of ______________, 20 ____ . ___________________________________________________ Signature I declarened copies: _______________________________________________________________________ _______________________________________________________________________ ____________________________________________rstand the information contained in the disclosure statement. The original of this document will be kept at ___________________________________ and the following persons and institutions will have sig____________ (address and telephone numbers) as alternate agent. I hereby acknowledge that I have been provided with a disclosure statement explaining the effect of this document. I have read and undent above is unable, unwilling or unavailable to act as my health care agent, I hereby appoint __________________________________________. (name of Agent) of ___________________________________________t the primary purpose of which is to prolong my life. ____________ (initial) I want my life sustained by any reasonable medical measures, regardless of my condition. In the event the person I appoithe ability to think and act for myself, I want care directed to my comfort and dignity and also want artificial nutrition and hydration if needed, but authorize my agent to decline all other treatmening artificial nutrition and hydration) the primary purpose of which is to prolong my life. 1 ____________ (initial) If I suffer a condition from which there is no reasonable prospect of regaining which there is no reasonable prospect of regaining my ability to think and act for myself, I want only care directed to my comfort and dignity, and authorize my agent to decline all treatment (includSTATEMENTS, YOU MAY IINITIAL THE STATEMENT APPROPRIATE STATEMENT IN THE SPACE PROVIDED (you should delete or cross-out the inapplicable statements): ____________ (initial) If I suffer a condition fromANCE. For your convenience in dealing with that subject, some general statements concerning the withholding or removal of life-sustaining treatment are set forth below. IF YOU AGREE WITH ONE OF THESE ___________________ _______________________________________________________________________ (attach additional pages as necessary) (b) THE SUBJECT OF LIFE-SUSTAINING TREATMENT IS OF PARTICULAR IMPORTon. _______________________________________________________________________ _______________________________________________________________________ ____________________________________________________or discontinue artificial nutrition and hydration; or instructions to refuse any specific types of treatment that are inconsistent with your religious beliefs or unacceptable to you for any other reas HEALTH CARE DECISIONS. Here you may include any specific desires or limitations you deem appropriate, such as when or what life-sustaining measures should be withheld; directions whether to continue durable power of attorney for health care shall take effect in the event I become unable to make my own health care decisions. (a) STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS REGARDING of Agent) of _______________________________ (address and telephone numbers)as my agent to make any and all health care decisions for me, except to the extent I state otherwise in this document. Thisu. 2 Durable Power Of Attorney For Health Care I , ________________________________________________________ (name of Principal) hereby appoint ________________________________________________. (nameent; your health or residential care provider or one of their employees; your spouse; your lawful heirs or beneficiaries named in your will or a deed; creditors or persons who ha ve a claim against yo2) OR MORE QUALIFIED WITNESSES WHO MUST BOTH BE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE. THE FOLLOWING PERSONS MAY NOT ACT AS WITNESSES: · · · · · the person you have designated as your ag your agent. Any alternate agent you designate will have the same authority to make health care decisions for you. THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS SIGNED IN THE PRESENCE OF TWO (d. If you want to make changes in the document you must make an entirely new one. You may wish to designate an alternate agent in the event that your agent is unwilling, unable or ineligible to act as your objection. You have the right to revoke the authority granted to your agent by informing him or her or your health care provider orally or in writing. This document may not be changed or modifier behalf. Even after you have signed this document, you have the right to make health care decisions for yourself as long as you are able to do so, and treatment cannot be given to you or stopped overa signed copy. You should indicate on the document itself the people and 1 institutions who will have signed copies. Your agent will not be liable for health care decisions made in good faith on youoth at the same time. You should inform the person you appoint that you want him or her to be your health care agent. You should discuss this document with your agent and your physician and give each or residential care home, other than a relative), that person will have to choose between acting as your agent or as your health or residential care provider; the law does not permit a person to do beone you know and trust and must be at least 18 years old. If you appoint your health or residential care provider (e.g. your physician, or an employee of a home health agency, hospital, nursing home, assistance to complete this document, but if there is anything in this document that you do not understand, you should ask a lawyer to explain it to you. The person you appoint as agent should be soms which may be made on your behalf. If you do not have a physician, yo u should talk with someone else who is knowledgeable about these issues and can answer your questions. You do not need a lawyer'su would have had. It is important that you discuss this document with your physician or other health care providers before you sign it to make sure that you understand the nature and range of decisiont will be obligated to follow your instructions when making decisions on your behalf. Unless you state otherwise, your agent will have the same authority to make decisions about your health care as yos authority will begin when your doctor certifies that you lack the capacity to make health care decisions. You may attach additional pages if you need more space to complete your statement. Your agen may make decisions about withdrawing or withholding life-sustaining treatment. You may state in this document any treatment you do not desire or treatment you want to be sure you receive. Your agent'ental condition. Your agent therefore can have the power to make a broad range of health care decisions for you. Your agent may consent, refuse to consent, or withdraw consent to medical treatment and and all health care decisions for you when you are no longer capable of making them yourself. "Health care" means any treatment, service or procedure to maintain, diagnose or treat your physical or mDOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS: Except to the extent you state otherwise, this document gives the person you name as your agent the authority to make anymers and Terms of Use found at findlegalforms.com 3 Vermont Durable Power Of Attorney for Health Care INFORMATION CONCERNING THE DURABLE POWER OF ATTORNEY FOR HEALTH CARE THIS IS AN IMPORTANT LEGAL with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaiting 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 attorney is always recommended when dealinggal 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 forms should only be a staral's care of the revocation. [_] 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 purpose or as to their le durable power of attorney for health care shall immediately record the revocation in the principal's medical record and notify the agent, the attending physician and staff responsible for the principr (3) by the divorce of the principal and spouse, where the spouse is the principal's agent. (b) A principal's health or residential care provider who is informed of or provided with a revocation of aare provider orally, or in writing, or by any other act evidencing a specific intent to revoke the power; (2) by execution by the principal of a subsequent durable power of attorney for health care; o express direction. 14 V.S.A. § 3457. (Revocation) (a) A durable power of attorney for health care shall be revoked: 2 (1) by notification by the principal to the agent or a health or residential cncipal is physically unable to sign, the durable power of attorney for health care may be signed by the principal's name written by some other person in the principal's presence and at the principal'se time the durable power of attorney for health care was signed and that the principal affirmed that he or she was aware of the nature of the documents and signed it freely and voluntarily. If the priny other person who has, at the time of execution, any claims against the estate of the principal. The witnesses shall affirm that the principal appeared to be of sound mind and free from duress at thal's spouse, heir, or reciprocal beneficiary, a person entitled to any part of the estate of the principal upon the death of the principal under a will or deed in existence or by operation of law or af at least two or more subscribing witnesses, neither of whom shall, at the time of execution, be the agent, the principal's health or residential care provider or the provider's employee, the princip an employee of the principal's residential care provider. 14 V.S.A. § 3456. (Execution and witnesses) The durable power of attorney for health care shall be signed by the principal in the presence oare provider; (2) a nonrelative of the principal who is an employee of the principal's health care provider; (3) the principal's residential care provider; or (4) a nonrelative of the principal who is2 of Title 18. 14 V.S.A. § 3455. (Restrictions on who can act as agent) A person may not exercise the authority of agent while serving in one of the following capacities: (1) the principal's health cder" means an individual or facility licensed, certified or otherwise authorized or permitted by law to operate, for profit or otherwise, a residential care home as that term is defined in section 200in the office on aging pursuant to the Older Americans Act of 1965, as amended. (8) "Principal" means an adult who has executed a durable power of attorney for health care. (9) "Residential care proviare, for profit or otherwise, in the ordinary course of business or professional practice. 1 (7) "Ombudsman" means a person appointed as a long-term care ombudsman under the program established withor treat an individual's physical or mental condition. (6) "Health care provider" means an individual or facility licensed, certified or otherwise authorized or permitted by law to administer health ccordance with the provisions of this chapter. (5) "Health care decision" means consent, refusal to consent, or withdrawal of consent to any care, treatment, service or procedure to maintain, diagnose reasonable alternatives to any proposed health care. (4) "Durable power of attorney for health care" means a document delegating to an agent the authority to make health care decisions executed in ac. (3) "Capacity to make health care decisions" means the ability to understand and appreciate the nature and consequences of a health care decision, including the significant benefits and harms of anddurable power of attorney for health care. (2) "Attending physician" means the physician, selected by or assigned to a patient, who has primary responsibility for the treatment and care of the patient make health care decisions on their beha lf. 14 V.S.A. § 3452. (Definitions) As used in this chapter: (1) "Agent" means an adult to whom authority to make health care decisions is delegated under a 451. (Statement of purpose) The purpose of this chapter is to enable adults to retain control over their own medical care during periods of incapacity through the prior designation of an individual totutes Title 14 Chapter 121 Section 3466. For your convenience, we have included useful excerpts from the Vermont Statutes relating to the Durable Power Of Attorney For Health Care Form. 14 V.S.A. § 3lating to the Durable Power Of Attorney For Health Care Form; (2) Vermont Durable Power Of Attorney For Health Care Form. This Vermont Durable Power Of Attorney For Health Care is based on Vermont Sta Durable Power Of Attorney For Health Care This package contains (1) Informa tion and Instruction for Vermont Durable Power Of Attorney For Health Care, including excerpts from the Vermont Statutes rent should 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 Information and Instructions Vermontt to make 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 documer legal 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 firsress 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 folth Care Directive. The first form is the Power of Attorney for Health Care and the second form is the Terminal Care Document (Living Will). [_] These forms are provided "as is" and no implied or expVermont Advance Health Care Directive This package contains both a Vermont Power of Attorney for Health Care and a Vermont Living Will. Together these forms are also sometimes known as an Advance Hea Vermont