SBCERS SPECIAL DURABLE POWER OF ATTORNEY FORM

SBCERS SPECIAL DURABLE POWER OF ATTORNEY FORM
This document is intended for appointing an Attorney-In-Fact to
transact all retirement matters relating to the Santa Barbara County
Employees’ Retirement System. It authorizes the person you
designate (called an “Attorney-In-Fact”) to handle your
retirement affairs such as filing applications, making benefit
elections, designating beneficiaries, and endorsing warrants.
This document creates a durable power of attorney which continues
after you, the principal, become incapacitated or otherwise unable to
handle your own affairs. This Special Durable Power of Attorney form
can only be used for SBCERS retirement matters. Do not complete
this form if you want this power of attorney to terminate when you
become incapacitated.
1. Creation of Special Durable Power of Attorney for Retirement-Related Business
By this document, I intend to create a Special Durable Power of
Attorney by appointing the person named below to make retirementrelated decisions for me as allowed by the California Probate Code.
This power is expressly limited to decisions relating to my benefits as
a member of the Santa Barbara County Employees’ Retirement
System—hereinafter SBCERS.
2. Designation of Attorney-In-Fact
I, ___________________________________________________________________________________________________________________ ,
SBCERS Member Name
of ______________________________________________________ , City of ______________________________________________________ ,
Street Address
County of ___________________________________________________ , State of __________________________________________________ ,
do hereby appoint: _________________________________________ (Relationship to Member ________________________________________ )
Name of Attorney-In-Fact
of ______________________________________________________ , City of ______________________________________________________ ,
Street Address
County of _________________________________________ , State of _________________________________________ , as my Attorney-In-Fact
3. General Statement of Authority Granted
If I become incapable of giving informed consent to decisions
concerning my retirement benefits, I hereby grant to my Attorney-InFact full power and authority to transact all matters relating to
SBCERS including, but not limited to filing applications, making
benefit elections, designating beneficiaries, and endorsing warrants.
I further give and grant unto my said Attorney-In-Fact full power and
authority to do and perform every act necessary and proper to be
done in the exercise of any of the foregoing powers as fully as I might
or could do if personally present, hereby ratifying and confirming all
that my said attorney shall lawfully do or cause to be done by virtue
hereof.
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4. Specific Authority for Spouse
This provision may ONLY be used if you are naming your spouse or domestic partner as your Attorney-In-Fact.*
 You must initial the line in front of each power you are granting.
_____ My Attorney-In-Fact is authorized to select any payment option available under the retirement plan, even though it may reduce the monthly
allowance which would otherwise be paid to me during my lifetime.
_____ My Attorney-In-Fact is authorized to designate himself or herself as my beneficiary.
On the following lines, you may give special instructions which limit or extend the powers granted your Attorney-In-Fact.
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
* To elect any option or designate any beneficiary on behalf of a member, an AttorneyIn-Fact must be either an eligible spouse or domestic partner who has been given
specific authority to do so or a “neutral” party. (An Attorney-In-Fact is neutral if he or
she is not related by blood or marriage to either the member or the designated
beneficiary). If the Attorney-In-Fact is not neutral, SBCERS will only accept the
following: an election of the “Unmodified Option” made on the member’s behalf and/or
the designation of the member’s minor child(ren) as beneficiary(ies). If a non-neutral
Attorney-In-Fact wishes to take any other action, he or she must obtain
conservatorship of the member.
If the Attorney-In-Fact is neutral, SBCERS will accept the election of any payment
option or the designation of any beneficiary, so long as it does not benefit the AttorneyIn-Fact.
5. Duration of Special Durable Power of Attorney
Note: This language creates a Special Durable Power of Attorney.
My Attorney-In-Fact is hereby instructed to notify SBCERS in writing
of my disability or incapacity or of my death immediately upon this
occurrence. My subsequent disability or incapacity shall not affect
this power of attorney. However, it will terminate upon my death.
 Please initial to indicate you want to be a Special Durable Power of Attorney.
_____ This Special Durable Power of Attorney will remain in effect for my lifetime or until I specifically cancel it.
Do not initial and do not complete this form if you want this power of attorney form to terminate when you become incapacitated.
 IMPORTANT REMINDERS: The authority granted by
SBCERS’s Special Durable Power of Attorney form is limited to
matters relating to SBCERS. The person designated on this form as
your Attorney-In-Fact does not have any authority over your other
real or personal property. You may note that the language contained
in the following “WARNING” section refers to more extensive
authority. This “WARNING” is required by Probate Code section
4128 to be included in all preprinted power of attorney forms that
may extend authority beyond the time you become disabled or
incapacitated. If you wish that your Attorney-In-Fact’s authority to be
extended over real and/or personal property matters, it is
recommended that you seek legal counsel in completing a different
power of attorney. Also, if you are concerned with the warning
statement or the extent of the authority being granted by this form,
we again urge you to consult with a private lawyer.
6. Notice to Person Executing this Document
A durable power of attorney is an important legal document. By
signing the durable power of attorney, you are authorizing
another person to act for you, the principal. Before you sign this
durable power of attorney, you should know these important
facts:
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 Your agent (Attorney-In-Fact) has no duty to act unless you
and your agent agree otherwise in writing.
 This document gives your agent the powers to manage,
dispose of, sell, and convey your real and personal property,
and to use your property as security if your agent borrows
money on your behalf. This document does not give your
agent the power to accept or receive any of your property, in
trust or otherwise, as a gift, unless you specifically authorize
the agent to accept or receive a gift.
 You can amend or change this durable power of attorney only
by executing a new durable power of attorney or by executing
an amendment though the same formalities as an original.
You have the right to revoke or terminate this durable power
of attorney at any time, so long as you are competent.
 Your agent will have the right to receive reasonable payment
for services provided under this durable power of attorney
unless you provide otherwise in this power of attorney.
 This durable power of attorney must be dated and must be
acknowledged before a notary public or signed by two
witnesses. If it is signed by two witnesses, they must witness
either (1) the signing of the power of attorney or (2) the
principal’s signing or acknowledgment of his or her signature.
This durable power of attorney that may affect real property
should be acknowledged before a notary public so that it may
be easily recorded.
 The powers you give your agent will continue to exist for your
entire lifetime, unless you state that the durable power of
attorney will last for a shorter period of time or unless you
otherwise terminate the durable power of attorney. The
powers you give your agent in this durable power of attorney
will continue to exist even if you can no longer make your
own decisions respecting the management of your property.
 You should read this durable power of attorney very carefully.
When effective, this durable power of attorney will give your
agent the right to deal with property that you now have or
might acquire in the future. The durable power of attorney is
important to you. If you do not understand the durable power
of attorney, or any provision of it, then you should obtain the
assistance of an attorney or other qualified person.
7. Date and Signature of Principal
Executed this _____ day of ________________________________________ , 20_____ ,
at _________________________________________________________ , _________________________________________________________
City
State
Signature: _____________________________________________________________________________________________________________
Print name: _________________________________________________________________ Employee No.: ______________________________
8. Notice to Person Accepting the Appointment as Attorney-In-Fact
By acting or agreeing to act as the agent (attorney-in-fact) under this power of attorney, you assume the fiduciary and other legal responsibilities of
an agent. These responsibilities include:
1. The legal duty to act solely in the interest of the principal and to avoid conflicts of interest.
2. The legal duty to keep the principal’s property separate and distinct from any other property owned or controlled by you.
You may not transfer the principal’s property to yourself without full and adequate consideration or accept a gift of the principal’s property unless this
power of attorney specifically authorizes you to transfer property to yourself or accept a gift of the principal’s property. If you transfer the principal’s
property to yourself without specific authorization in the power of attorney, you may be prosecuted for fraud and/or embezzlement. If the principal is
65 years of age or older at the time that the property is transferred to you without authority, you may also be prosecuted for elder abuse under Penal
Code Section 368. In addition to criminal prosecution, you may also be sued in civil court.
I have read the foregoing notice and I understand the legal fiduciary duties that I assume by acting or agreeing to act as the agent (attorney-in-fact)
under the terms of this power of attorney.
Date and Signature of Accepting Attorney-In-Fact:
Date: _________________________________________ Signature of agent: _______________________________________________________
Print name of agent: _____________________________________________________________________________________________________
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9a. Signature of Witnesses
1. I, _______________________________________________ ,
have witnessed the principal’s signature, or the principal’s
acknowledgement of the signature designating power of attorney. I
am an adult, at least 18 years old and NOT THE ATTORNEY-INFACT. My signature certifies that the principal is known to me, and is
the same person who signed and dated this affidavit.
2. I, _______________________________________________ ,
have witnessed the principal’s signature, or the principal’s
acknowledgement of the signature designating power of attorney. I
am an adult, at least 18 years old and NOT THE ATTORNEY-INFACT. My signature certifies that the principal is known to me, and is
the same person who signed and dated this affidavit.
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
Print your name here
Print your name here
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
City, State, Zip Code
City, State, Zip Code
Signature
Signature
Street Address
Street Address
---OR--9b. Acknowledgement of Notary Public (California Version)
County of __________________________________________________
On _________________________________________________ , before me, ______________________________________________________ ,
personally appeared ____________________________________________________________________________________________________ ,
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and
acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the
instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.
Witness my Hand and Official Seal
Seal
Signature of Notary Public: ________________________________________________________________
This acknowledgement form is valid for California notaries only!
If notarized outside the State of California, the notary of the applicable state must complete and
attach that state’s acknowledgement form.
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