Power of Attorney Form.xlsx

SPECIAL POWER OF ATTORNEY
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 that
person's behalf.
SECTION 2
You have the option of
designating more than
one Attorney-in-Fact.
Creation of Special Durable Power of Attorney for Retirement-Related Business
Name of Principal (First Name, Middle Initial, Last Name)
Social Security Number or SJCERA ID
Address
County
(
City
State
Zip
)
Daytime Phone
By this document I intend to create a durable power of attorney by appointing the person 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 benefits under the San Joaquin County Employees' Retirement Association, hereinafter
SJCERA.
Designation of Attorney-in-Fact
If you appoint 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 (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
Address
Social Security Number
(
City
State
Zip
)
Daytime Phone
Name of Attorney-in-Fact (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
Address
Social Security Number
(
City
State
Zip
)
Daytime Phone
Name of Attorney-in-Fact (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
Address
Social Security Number
(
City
State
Zip
)
Daytime Phone
I have designated more than one Attorney-in-Fact. They are to act (mark one box only):
☐ Jointly
☐ Separately
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.
SJCERA Special POA 2014
Page 1 of 5
Put your name and
Social Security
Number or SJCERA
ID at the top of every
page
SECTION 3
Name of Principal
Social Security Number or SJCERA ID
General Statement of Authority Granted
I hereby grant my Attorney-in-Fact full authority to transact all matters on my behalf relating to SJCERA,
including, but not limited to, filing applications, making benefit elections, designating beneficiaries and endorsing
warrants. I further give my Attorney-in-Fact full authority to perform every required act to be done to exercise any
of the foregoing powers as fully as I might or could do if personally present, hereby ratifying and confirming all
that my Attorney-in-Fact shall lawfully do or cause to be done. I understand that this authority is granted to the
Attorney-in-Fact designated by me even if that person is related to be my blood, marriage, or legal domestic
partnership. By signing this Special Power of Attorney form, I intend that:
Ÿ
Ÿ
Ÿ
Ÿ
SECTION 4
Please be careful in
choosing when you
want your power of
attorney to commence
or terminate.
My Attorney-in-Fact (☐ is; ☐ 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.
(☐ is; ☐ is not) authorized to designate or change my beneficiary.
My Attorney-in-Fact (☐ is; ☐ is not) authorized to designate himself or herself as my beneficiary.
My Attorney-in-Fact
I give the following instructions that limit or extend the powers granted to my Attorney-in-Fact:
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 SJCERA in writing of my disability, incapacity, or death
immediately upon its occurrence.
☐ This special durable power of attorney is to commence immediately and to remain in effect for my lifetime or
until I specifically cancel it.
☐ This special limited power of attorney is to commence on ____________________ and
terminate on ____________________________ .
Date (mm/dd/yyyy)
Date (mm/dd/yyyy) or Event
☐ 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
☐ This special general power of attorney is to terminate in its entirely if I become incapacitated.
SJCERA Special POA 2014
Page 2 of 5
Put your name and
Social Security
Number or SJCERA
ID at the top of every
page
SECTION 5
Agent is the
Attorney-in-Fact.
Name of Principal
Social Security Number or SJCERA ID
Notice to Person Executing Durable Power of Attorney
The authority granted by the SJCERA Special Power of Attorney form is limited to matters related to SJCERA.
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 SJCERA Speical Power of Attorney. This (Warning) statement is required by
California Probate Code Section 4128 to be included in all pre-printed power of attorney forms even though the
SJCERA 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 SJCERA Special Power of Attorney form, we again urge you to consult with an
attorney.
(Warning): Notice to Person Executive Durable Power of Attorney
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:
Ÿ
Ÿ
Your agent 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.
Ÿ
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.
Ÿ
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.
Ÿ
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 durable power of attorney at any time, so long as you are competent.
Ÿ
This durable power of attorney must be dated and must be acknowledged before a notary public or signed
by two witnesses. (Please choose one or the other, but not both!) 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. A durable power of attorney that may affect real property should be acknowledged before a
notary public so that it may be easily recorded.
Ÿ
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.
SJCERA Special POA 2014
Page 3 of 5
Put your name and
Social Security
Number or SJCERA
ID at the top of every
page
SECTION 6
To be reviewed and
signed by the Attorneyin-Fact
Name of Principal
Social Security Number or SJCERA ID
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:
Ÿ
The legal duty to act solely in the interest of the principal and to avoid conflicts of interest
Ÿ
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.
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 and 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.
Print Name of Principal
Social Security Number or SJCERA ID
Signature of Principal
County
City
State
SJCERA Special POA 2014
Date Executed (mm/dd/yyyy)
Page 4 of 5
Put your name and
Social Security
Number or SJCERA
ID at the top of every
page
SECTION 8
To be completed and
signed by two
witnesses who are not
named as Attorneysin-Fact.
Name of Principal
Social Security Number or SJCERA ID
Witness Information
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 the Principal is of sound mind.
Signature of Witness 1
Date (mm/dd/yyyy)
Print Name of Witness 1
Witness 1 Address
City
State
Signature of Witness 1
Zip
Date (mm/dd/yyyy)
Print Name of Witness 1
Witness 1 Address
City
SECTION 9
To be completed by a
notary public.
This section does not
need to be completed
if you have completed
Section 8. SJCERA
images these
documents. Please
be advised embossed
seals may not appear
when this document is
imaged. An inked
stamp is preferred.
State
Zip
Notary Public Acknowledgement
Notary
State
On
County
_______________________ before me ________________________________________________,
Date (mm/dd/yyyy)
Printed Name of Notary Public
personally appeared ________________________________________, who proved to me on the basis of
Printed Name of Principal
satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to
me that he/she exeucted the same in his/her authorized capacity, and that by his/her signature on the instrument
the person, or the entity upon behalf of which the person 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
Printed Name of Notary Public
MAIL TO:
SJCERA Ÿ 6 S. El Dorado Street, Suite 400 Ÿ Stockton, California Ÿ 95202-2804
SJCERA Special POA 2014
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