UNIFORM STATUTORY FORM POWER OF ATTORNEY

RECORDING REQUESTED BY:
AND WHEN RECORDED MAIL TO:
SPACE ABOVE THIS LINE IS FOR RECORDER'S USE
UNIFORM STATUTORY FORM POWER OF ATTORNEY
(California Civic Code Sec. 4401)
NOTICE: THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD AND SWEEPING, THEY ARE EXPLAINED IN THE
UNIFORM STATUTORY FORM POWER OF ATTORNEY ACT (CALIFORNIA CIVIC CODE SECTION 4400-4465, INCLUSIVE).
IF YOU HAVE ANY QUESTIONS ABOUT THESE POWERS, OBTAIN COMPETENT LEGAL ADVICE THIS DOCUMENT DOES
NOT AUTHORIZE ANYONE TO MAKE MEDICAL AND OTHER HEALTH-CARE DECISIONS FOR YOU. YOU MAY REVOKE THIS
POWER OF ATTORNEY IF YOU LATER WISH TO DO SO.
(your name and address)
appoint
(name and address of the person appointed, or of each person appoints if you want to designate more than one)
as my agent (attorney-in-fact) to act for me in any lawful way with respect to the following initialed subjects:
TO GRANT ALL OF THE FOLLOWING POWERS INITIAL THE LINE IN FRONT OF (N) AND IGNORE THE
LINES IN FRONT OF THE OTHER POWERS.
TO GRANT ONE OR MORE, BUT FEWER THAN ALL OF THE FOLLOWING POWERS, INITIAL THE LINE IN
FRONT OF EACH POWER YOU ARE GRANTING.
TO WITHHOLD A POWER, DO NOT INITIAL THE LINE IN FRONT OF IT, YOU MAY, BUT NEED NOT, CROSS
OUT EACH POWER WITHHELD.
INITIAL
INITIAL
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
Real property transactions.
Tangible personal property transaction
Stock and bond transactions
Commodity and option transaction.
Banking and other financial institution
transaction
Business operating transactions.
Insurance and annuity transactions
Estate, Trust, and other beneficiary.
transactions.
(I)
(J)
(K)
(L)
(M)
(N)
Claims and litigation.
Personal and family maintenance
Benefits from social security, Medicare,
Medicaid, or other governmental programs,
or civil or military service
Retirement plan transactions
Tax matters.
ALL OF THE POWERS LISTED ABOVE.
YOU NEED NOT INITIAL ANY OTHER LINES IF YOU INITIAL LINE (N)
Page (1) of (2)
SPECIAL INSTRUCTIONS:
ON THE FOLLOWING LINES YOU MAY GIVE SPECIAL INSTRUCTIONS LIMITING OR EXTENDING THE
POWERS GRANTED TO YOUR AGENT:
UNLESS YOU DIRECT OTHERWISE ABOVE, THIS POWER OF ATTORNEY IS EFFECTIVE IMMEDIATELY AND
WILL CONTINUE UNTIL IT IS REVOKED.
This power of attorney will continue to be effective even though I become incapacitated.
STRIKE THE PRECEDING SENTENCE IF YOU DO NOT WANT THIS POWER OF ATTORNEY TO CONTINUE IF
YOU BECOME INCAPACITATED.
EXERCISE OF POWER OF ATTORNEY WHERE MORE THAN ONE AGENT DESIGNATED
If I have designated more than one agent, the agents are to act
IF YOU APPOINTED MORE THAN ONE AGENT AND YOU WANT EACH AGENT TO BE ABLE TO ACT ALONG
WITHOUT THE OTHER AGENT JOINING, WRITE THE WORD “SEPARATELY” IN THE BLANK SPACE ABOVE. IF
YOU DO NOT INSERT ANY WORD IN THE BLANK SPACE, OR IF YOU INSERT THE WORD “JOINTLY”, THEN ALL
OF YOUR AGENTS MUST ACT OR SIGN TOGETHER.
I agree that any third party who receives a copy of this document may act under its. Revocation of the power of
attorney is not effective as to a third party until the third party has actual knowledge of the revocation. I agree to indemnify
the third party for any claims that arise against the third party because of reliance on this power of attorney.
Signed this __________ day of ___________________________________________, _____________
Your Signature
Your Social Security Number
STATE OF __________________________________________}
COUNTY OF
}SS.
On
before me,
(insert name) Notary Public,
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 foregoing paragraph is true and
correct.
witness my hand and official seal.
Signature
(This area for official notarial seal)
Page (2) of (2)
Notice required by Probate Code Section 4128:
Notice to Person Executing 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:
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 provide 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
respecting 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 durable power of
attorney at any time, so 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 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 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. 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.
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 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.
Date:
____________________________
(Signature of agent)
____________________________
(Print name of agent)