CalPERS Special Power of Attorney Form

Special Power of Attorney
888 CalPERS (or 888-225-7377) • TTY for Speech and Hearing Impaired: (916) 795-3240 • Fax (916) 795-3934
Section 1
When completing this form,
please be sure to print the
requested information.
For the purpose of this
form, a principal is
defined as a person who
empowers another to act
as a representative on
their behalf.
Section 2
You have the option of
designating more than one
attorney-in-fact.
Creation of Durable Power of Attorney for Retirement-Related Business
–
–
Name of Principal (First Name, Middle Initial, Last Name)
Social Security Number
Address
County
(
City
State
ZIP
)
Daytime Phone
By this document I intend to create a durable power of attorney by appointing the person(s) named
below to make retirement-related decisions for me as allowed by the California Probate Code. This
power is expressly limited to decisions relating to my financial and health benefits under the California
Public Employees’ Retirement System, the Legislators’ Retirement System, or the Judges’ Retirement
System I or II — hereinafter CalPERS, LRS, JRS I and JRS II, respectively.
Designation of Attorney-In-Fact
If you appointed more than one attorney-in-fact, and you want each attorney-in-fact to be able to act
alone, check the appropriate box. If you do not check a box, or if you check “jointly,” then all of your
attorneys-in-fact must act or sign together. Granting joint authority to two or more attorneys-in-fact is
exercisable only by their unanimous action. If you choose to have your attorneys-in-fact act jointly, and one
is unavailable because of absence, illness, or other temporary incapacity, the other attorney(s)-in-fact may
exercise their authority under the power of attorney.
Name of attorney-in-fact
Address
County
(
City
State
ZIP
)
Daytime Phone
Name of attorney-in-fact
Address
County
(
City
State
ZIP
)
Daytime Phone
Name of attorney-in-fact
Address
County
(
City
State
ZIP
)
Daytime Phone
I have designated more than one attorney-in-fact. They are to act (mark one box only):
F
Jointly F Separately F Alternately, in the numerical order specified above. If you mark “Alternately,”
you must number the attorneys-in-fact in the order in which they are to act.
PERS-OSS-138 (8/09)
Page 1 of 5
Put your name and
Social Security number
at the top of every page.
Section 3
–
Name of Principal
–
Social Security Number
General Statement of Authority Granted
I hereby grant to my attorney-in-fact full power and authority to transact matters on my behalf relating to
CalPERS, LRS, JRS I or JRS II. I understand that this authority is granted to the attorney-in-fact designated
by me even if that person is related to me by blood, marriage, or legal domestic partnership. By signing
this Special Power of Attorney form I intend that:
•
My attorney-in-fact ( F is; F is not) authorized to select any payment option available under the
retirement plan, even though it may reduce the monthly allowance that would otherwise be paid
to me during my lifetime.
•
My attorney-in-fact ( F is; F is not) authorized to designate or change my beneficiary.
•
My attorney-in-fact ( F is; F is not) authorized to designate him or herself as my beneficiary.
On the following lines you may give special instructions limiting the powers granted to your
attorney(s)-in-fact.
Section 4
Please be careful in
choosing when you want
your power of attorney to
commence or terminate.
Duration of Power of Attorney
Please check one box to indicate your choice.
Unless I indicate otherwise, this power of attorney is effective immediately and will continue until it is
revoked. My attorney-in-fact is hereby instructed to notify CalPERS in writing of my disability, incapacity,
or death immediately upon its occurrence.
F
This special Durable power of attorney is to commence immediately and to remain in effect for my
lifetime or until I specifically cancel it.
F
This special Limited power of attorney is to commence on _________________ and terminate on
Date (mm/dd/yyyy)
______________________________.
Date (mm/dd/yyyy) or Event
F
This special Contingent power of attorney is to commence only upon a determination that I am
incapacitated and/or unable to handle my own affairs. The determination of whether I am
incapacitated and/or unable to handle my own affairs shall be made by
______________________________________________________.
Name or Title of Person to make the determination
F
PERS-OSS-138 (8/09)
This special General power of attorney is to terminate in its entirety if I become incapacitated.
Page 2 of 5
Put your name and
Social Security number
at the top of every page.
Section 5
Agent is the
attorney-in-fact
–
Name of Principal
–
Social Security Number
Notice to Person Executing Durable Power of Attorney
The authority granted by the CalPERS Special Power of Attorney form is limited to matters relating to
CalPERS, LRS, JRS I and JRS II. The person designated as your attorney-in-fact does not have any authority
over your other real or personal property. If you wish that your attorney-in-fact have authority over your real
and/or personal property, it is recommended that you seek legal counsel.
You may notice that the language contained in the following (Warning) statement refers to more extensive
authority than granted by the CalPERS Special Power of Attorney. This (Warning) statement is required by
Probate Code Section 4128 and must be included in all preprinted durable power of attorney forms even
though the CalPERS Special Power of Attorney does not authorize your attorney-in-fact to do many of
the things mentioned in the following (Warning) statement. Also, if you are concerned with the (Warning)
statement or the extent of the authority being granted by the CalPERS Special Power of Attorney form, we
again urge you to consult with an attorney.
(Warning): Notice to Person Executing Durable Power of Attorney
A durable power of attorney is an important legal document. By signing a 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:
PERS-OSS-138 (8/09)
•
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.
•
Your agent will have the right to receive reasonable payment for services provided under this
durable power of attorney unless you state otherwise in this power of attorney.
•
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 regarding the management of
your property.
•
You can amend or change this durable power of attorney only by executing a new durable power of
attorney or by executing an amendment through the same formalities as an original. You have the
right to revoke or terminate this power of attorney at any time as long as you are competent.
•
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
principal’s signing of the power of attorney or (2) the principal’s acknowledgement of his or her
signature. A durable power of attorney that may affect real property should be acknowledged before
a notary public so that it can easily be recorded.
•
You should read this durable power of attorney 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. This durable power of attorney is important to you. If you do not understand the durable
power of attorney or any provision of it, you should obtain the assistance of an attorney or other
qualified person.
Page 3 of 5
Put your name and
Social Security number
at the top of every page.
Section 6
–
Name of Principal
–
Social Security Number
Notice to Person Accepting the Appointment of 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:
•
The legal duty to act solely in the interest of the principal and to avoid conflicts of interest.
•
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 authorized 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 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 and 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. Lastly, the
principal's benefit shall not be subject to execution, process, or assignment under California Public
Employees' Retirement Law Section Code 21255.
Print Name of Agent
Signature of Agent
Date (mm/dd/yyyy)
Print Name of Agent
Signature of Agent
Date (mm/dd/yyyy)
Print Name of Agent
Signature of Agent
Section 7
To be completed and
signed by the Principal.
Date (mm/dd/yyyy)
Principal’s Acknowledgement & Execution
I am of sound mind and either understand my elections or talked with an attorney. I am executing this legal
document under my own free will.
Date Executed (mm/dd/yyyy)
City
State
Signature of Principal
County
Name of Principal (printed)
Social Security Number
–
PERS-OSS-138 (8/09)
Page 4 of 5
–
Put your name and
Social Security number
at the top of every page.
–
Name of Principal
–
Social Security Number
Section 8
Witness Information
To be completed by
two witnesses who
are not named as
attorneys-in-fact.
I have witnessed the principal’s signature or the principal’s acknowledgment of the signature designating
power of attorney. I attest to the principal’s knowledge that I am of sound mind. I am an adult at least 18
years old and not the attorney-in-fact. My signature certifies that the principal is known to me, is the same
person who signed and dated this affidavit, and that I am of sound mind.
Signature of Witness 1
Name of Witness 1 (printed)
Address
Date
City
State
Signature of Witness 2
Name of Witness 2 (printed)
Address
Date
City
State
Section 9
Notary Public Acknowledgement
To be completed by
a Notary Public.
Notary
State
This section does
not need to be
completed if you have
completed Section 8.
CalPERS images these
documents. Please
be advised embossed
seals may not appear
when this document
is reviewed. An inked
stamp is preferred.
ZIP
ZIP
County
On _______________ before me ____________________________________, personally appeared
Date (mm/dd/yyyy)
Printed Name of Notary Public
____________________________________, who proved to me on the basis of satisfactory evidence
Name of Principal
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.
Signature of Notary Public
Notary Seal
Print Name
Mail to:
PERS-OSS-138 (8/09)
CalPERS Benefit Services Division • P.O. Box 942716, Sacramento, California 94229-2716
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