APPENDIX A2

Durable General Power of Attorney

New York Statutory Short Form

e
l
p

R POWER OF ATTO
(a) CAUTION TO THE PRINCIPAL: YOUR
TTORNEY
CIPA 
YOU GIVE THE
IS AN IMPORTANT DOCUMENT. AS THE PRINCIPAL
PERSON WHOM YOU CHOOSE (YOUR AGENT
GENT AUTHORITY TO SPE
SP
SPEND

m
a

OSE OF YOUR PROPERTY DURIN

DU
YOUR MONEY AND SELL
DURING
LL OR DISPOSE
YO . YOU DO NO
YOUR LIFETIME WITHOUT TELLING YOU
NOT LOSE YOU
YOUR
AUTHORITY
Y TO ACT EVEN THOUGH YOU HAVE GIVEN YOUR AGENT
SIMILAR
TY.
LAR AUTHORITY

WHEN YOUR AGENT EXERCISES THIS AUTHO

AUTHORITY, HE OR SHE MUST
C ACCORDING
CORDING TO ANY INSTRUCTIO
ACT
INSTRUCTIONS YOU HAVE PROVIDED OR,
WHERE THERE ARE NO SPECIFIC
SPECI
INSTRUCTIONS, IN YOUR BEST
INTERES . ,MPORTANT
MPO
INTEREST
IN
NFORMATION FOR THE AGENT AT THE END
OF THIS DOCUMENT D
DESCRIBES YOUR AGENT'S RESPONSIBILITIES.
YOUR AG
AGENT CAN ACT ON YOUR BEHALF ONLY AFTER SIGNING THE
POW
OWER OF ATTORNEY BEFORE A NOTARY PUBLIC.

e
l
p

YOU CAN REQUEST INFORMATION FROM YOUR AGENT AT ANY TI

TIME.
IF YOU ARE REVOKING A PRIOR POWER OF ATTORNEY, YOU
OU SHOULD
SHOU

PROVIDE WRITTEN NOTICE OF THE REVOCATION TO YOUR PRI

PRIOR
PRIO
AGENT(S) AND TO ANY THIRD PARTIES WHO MAY
VE ACTED
A TED
D UPON IT,
Y HAVE
AC
INCLUDING THE FINANCIAL INSTITUTIONS
NS WHERE YOUR ACCOUNTS
ARE LOCATED.

m
a

TE YOUR POWER OF ATTORNEY

YOU CAN REVOKE OR TERMINATE
TTO
AT
ANY TIME FOR ANY
S
NY REASON AS LONG AS YOU ARE OF SOUND
MIND. IF
YOU ARE NO LONGER OF SOUND MIND, A COURT CAN REM
REMOVE AN
ING IMPROPERLY.
AGENT
NT FOR ACTING

YOUR AGENT CANNOT MAKE HE

HEALTH CARE D
DECISIONS FOR YOU. YOU
MAY EXECUTE A +EALTH CARE PROX
ROXY TO DO THIS.

GOV
THE LAW GOVERNING
POW
OWERS OF ATTORNEY IS CONTAINED IN THE
NEW YORK GENERA
ENERAL OBLIGATIONS LAW, ARTICLE 5, TITLE 15.
THIS
IS LAW IS AVAILABLE
AV
AT A LAW LIBRARY, OR ONLINE THROUGH
EW YORK STATE SENATE OR ASSEMBLY WEBSITES,
THE NE
WWW.SENATE. STATE.NY.US OR WWW.ASSEMBLY.STATE.NY.US.

IF THERE IS ANYTHING ABOUT THIS DOCUMENT THAT YOU DO NOT

UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING
TO EXPLAIN IT TO YOU.

e
l
p
m

(b) DESIGNATION OF AGENT(S):

I,

a
S

ncipal]
[name of principal]

[address of principal]

hereby appoint:

[name of agent]
[nam

[address of agent]

e
l
p
m

[name of second agent]

[name of third agent]

a
S

as my agent(s).
ent(s).

[address of secondd agent]

[address of third agent]

Iff you designate more than one agent above, they must act together
nless you init
unless
stateme below.
initial the statement
____) My agents
age may act SEPARATELY.
(______)

(c) DESIGNATION OF SUCCESSOR AGENT(S): (OPTIONAL)

e
l
p
m

If any agent designated above is unable or unwilling to serve,

erve, I appoint
as my successor agent(s):

[name of successor agent]

a
S

nd successor agent]
[name
name of second

a
[name of third successor agent]

ddress of successor agent

[address
agent]

[address of second su
successor agent]

[address of third successor agent]

Successor agents designated above must act together unless you initial
below.
the statement
s

e
l
p

(______) My successor agents may act SEPARATELY.

You may provide for specific succession rules in this

Insert
his section. Inse
specific succession provisions here:

m
a

(d) This POWER

TORNEY shall not be affected
affecte by my
R OF ATTORNEY
subsequent incapacity unless I have stated otherwise
otherwi below, under
u
0RGLILFDWLRQV
ILFDWLRQV

(e) This POWER OF ATTORNEY DOES NOT REVOKE any

Powers of Attorney previously executed by me unless I have stated
RWKHUZLVHEHORZXQGHU0RGLILFDWLRQV
RWKHUZLVHEHORZXQGHU
RWKHUZLVHEHORZXQGHU0RGLILFDW

Iff you do NO
NOT intend to revoke your prior Powers of Attorney, and if
you
u hhave granted the same authority in this Power of Attorney as you
granted
another agent in a prior Power of Attorney, each agent can act
ted to an
VHSDUDWHO\XQOHVV\RXLQGLFDWHXQGHU0RGLILFDWLRQVWKDWWKHDJHQWVZLWK
the same authority are to act together.

(f) GRANT OF AUTHORITY:

e
l
p

To grant your agent some or all of the authority below, either

er
(1)

Initial the bracket at each authority youu grant, or

(2)

Write or type the letters for each authority

hority you grant on the
blank line at (P), and
d initial the bracket at (P). If you initia
initial ((P),
you do not need
ed to initial thee other lines.

m
a

I grant authority
subjects as
follo
ority to my agent(s) with respect to the following
subj
defined
General
ed in sections 5-1502A through 5-1502N of the New York
Y
ns Law:
Obligations

S
(______)
(______)
(______)
(______)
(
(______)
(______)
((______)
(______)
(______)

(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)

trans
real estate transactions;
transactions;
chattel an
and goods tr
bo
bond, share aand commodity transactions;
banking transactions;
bankin
business
operating transactions;
b
insurance transactions;
estate transactions;
claims and litigation;
personal and family maintenance. If you grant
nt yyour
agent this authority, it will allow the agentt to make gifts
gi
that you customarily have made to individuals,
including
dividuals, includin
ndividuals,
your agent, and charitable organizations.
zations. The total
amount of all such gifts in any one calendar
endar year cannot
exceed $500;
(______) (J) benefits from
al programs or civil or military
m governmental
service;
ce;
(______) (K) health caree billing and payment matters; records, rep
reports
ements
and statements;
(______)
transactions;
_____) (L) retirement benefit transaction
(______) (M) tax matters;
(______) (N) all other matters
matters;
(______) (O) full and unq
unqualified aauthority to my agent(s) to delegate
ny or all of the
any
po
foregoing powers
to any person or persons whom my agent(s) select;
(______)
of the matters identified by the following letters
_____)) (P) EACH
EA
A, B, C, D, E, F, G, H, I, J, K, L, M, N and O.

e
l
p

m
a

You need not initial the other lines if you initial line (P).

(g) MODIFICATIONS: (OPTIONAL)

e
l
p

In this section, you may make additional provisions, including

uding language
to limit or supplement authority granted to your agent. However,
Howev you
cannot use this Modifications section to grant
authority to
antt your agent autho
make major gifts or changes to interestss in your property. If you wi
wish to
w
grant your agent such authority, you MUST
T complete the Statutory Gifts
G
Rider.

m
a

(h) CERTAIN GIFT TRANSACTIONS:

NSACTIONS: STATUTORY GIFTS
RIDER:
ONAL)
R: (OPTIONAL)

excess of an annual total

In order to authorize your agent to make gifts in exc
of authority section of
of $500 for all gifts described in (I) of the grant
g
family maintenance), you must initial
perso
this document (under personal
and fam
an execute a Statutory Gifts Rider at the same time
the statement below and
Initialing
the statement below by itself does not
his instrument.
instrume
as this
Initial
authoriz your agent to make gifts. The preparation of the Statutory Gifts
authorize
Ride should be
Rider
b supervised by a lawyer.
((______) (SGR) I grant my agent authority to make gifts in accordance
with the terms and conditions of the Statutory Gifts
Rider that supplements this Statutory Power of
Attorney.

e
l
p
m
a

(i) DESIGNATION OF MONITOR(S): (OPTIONAL)

L)
OPTIONAL)

If you wish to appoint monitor(s),

s), initial andd fill in the section below:

(______) I wish to designate ____________________________,

_____________________
____________________________
, whose
address(es)
__________________________________,
_____________________
dress(es) is (are) _______________________________
as monitor(s).
monitor(s), my
tor(s). Upon the request of the mo
m agent(s)
must
st provide the monitor(s) with a copy
cop of the Power of
Attorney and a record of all transactions
transaction done or made on my
behalf. Third parties holding
records
h
reco of such transactions shall
provide the reco
records to the monitor(s)
upon request.
m

(j) COMPENSATION OF AGENT(S): (OPTIONAL)

e
l
p

Your agent is entitled to be reimbursed from your assets for re

reasonable
expenses incurred on your behalf. If you ALSO wish
agent(s) to be
sh your agent
compensated from your assets for services rendered
endered on your behalf,
LQLWLDO WKH VWDWHPHQW EHORZ ,I \RX
X ZLVK WR GHILQH UHDVRQDEOH
UHDVR
FRPSHQVDWLRQ\RXPD\GRVRDERYHXQGHU0RGLILFDWLRQV
U0RGLILFDWLRQV
ERYHXQGHU0RGLILFDWLRQV

m
a

(______) My agent(s)
led to reasonable compensat
s) shall be entitled
compensation for
fo
services
ces rendered.
(k)) ACCEPTANCE
TANCE BY THIRD PARTIES:
PARTIES I agree to
t indemnify the
again the
third party for any claims that may arise against
th third party because
understand that any termination
of reliance on this Power of Attorney. I und
of this Power of Attorney
Attorney, whether tthe result of my revocation of the
otherwise, is not effective as to a third party until
Power of Attorney or otherwise
or knowledge of the termination.
h actual notice
the third party has
n

TERMINATION:
This Power of Attorney continues until I revoke it
T
(l) TERMINA
by my death or other event described in section 5-1511
or it is terminated
t
of the General Obligations Law.

e
l
p

Section 5-1511 of the General Obligations Law describes the manne

manner in
which you may revoke your Power of Attorney, and the events that
th
terminate the Power of Attorney.
(m) SIGNATURE AND ACKNOWLEDGMENT:
EDGMENT:

m
a

In Witness Whereof I have

gned my name on ________,
________
ve hereunto signed
20__.

==>___________________________________
PRINCIPAL signs here: ==>___________________

STATE OF NEW YORK

e
l
p

) ss.:
COUNTY OF ___________ )

m
a

On the _____ day of _____, in

the
n the year 20__, before me
me, th
undersigned, a Notary
appeared
perso
otary Publicc in and for said state, personally
appeare
___________,
lly known to me or proved to m
__, personally
me on the bbasis of
satisfactory
subscribed to the
nce to be the person whose name
nam is subs
actory evidence
trument and acknowledged to me that
tha he/she executed the same
within instrument
signature on the instrument, the
in his/her capacity, and that by his/her signatu
erson or the entity upon behalf
beha of which
person
whic the person acted executed the
instrument.

_______________________________
__________
Notary Public
P

(n) IMPORTANT INFORMATION FOR THE AGENT:

e
l
p
m
a

When you accept the authority granted under this Power of Attorney
Attorney, a
special legal relationship is created between you andd the principal. This
Th
Thi
relationship imposes on you legal responsibilities
ties that continue until you
resign or the Power of Attorney is terminated
d. You must:
nated or revoked.
(1)

act according to any

ny instructions from the principal, or, where
WKHUHDUHQRLQVWUXFWLRQVLQWKHSULQFLSDOVEHVWLQWHUHVW
LQWKHSULQFLSDOVEHVWLQWHUHV
LQVWUXFWLRQVLQWKHSULQFLSDOVEHVWLQWHUHVW

(2)

avoid conflictss that would impair your abi

ability to act in the
SDOVEHVWLQWHU
SULQFLSDOVEHVWLQWHUHVW

S
(3))

VHSDUDWH DQG Gistinct from any

NHHS WKH SULQFLSDOV SURSH
SURSHUW\ VHSDUD
unless otherwise permitted by law;
assets you own or co
control, unles

(4)

keep a record of all receipts, payments and transactions

con
conducted
for the principal; and

(5)

disclose your identity as an agent whenever you act for the

di
principal by writinJ RU SULQWLQJ WKH SULQFLSDOV QDPH DQG
VLJQLQJ \RXU RZQ QDPH DV DJHQW LQ HLWKHU RI WKH IROORZLQJ

PDQQHUV3ULQFLSDOV1DPHE\<RXU6LJQDWXUHDV$JHQWRU

\RXUVLJQDWXUHDV$JHQWIRU3ULQFLSDOV1DPH

e
l
p

<RXPD\QRWXVHWKHSULQFLSDOVDVVHWVWREHQHfit yourself
else
urself or anyone
any
or make gifts to yourself or anyone else unless the princip
principal has
specifically granted you that authority inn this document,
a
cument, which is either
ei
Statutory Gifts Rider attached to a Statutory Short Form Power
Powe of
Attorney or a Non-Statutory
ory Power of Attorney. If you have that
th
authority, you must act according to any instructions of the princ
principal or,
o
ZKHUHWKHUHDUHQRVXFKLQVWUXFWLRQVLQWKHSULQFLSDOVEHVWLQWHUHVW
XFWLRQVLQWKHSULQFLSDOVEHV
HQRVXFKLQVWUXFWLRQVLQWKHSULQFLSDOVEHVWLQWHUHVW

m
a

You
principal and to any
t princip
u may resign by giving written notice to the
co-agent,
-agent, successor agent, monitor if one has been named in this
co
GRFXPHQWRUWKHSULQFLSDOVJXDUGLDQLIRQHKDVEHHQDSSRLQWHG,IWKHUH
GRFXPHQWRUWKHSULQFLSDOVJXDUGLDQLIRQHK
or your
docu
is anything about this document
you responsibilities that you do not
legal advice.
understand, you shoul
should seek lega

Liability of agent: The

Th meaning of the authority given to you is defined
LQ1HZ<RUNV*HQHUDO2EOLJDWLRQV/DZ$UWLFOH7LWOH,ILWLVIRXQG
LQ
1H
LQ1HZ<RUNV
that you have violated the law or acted outside the authority granted to
you in the Power of Attorney, you may be liable under the law for your
yo
violation.

e
l
p

(o) $*(1766,*1$785($1'$&.12:/('*0(172)
0(172)
APPOINTMENT:

It is not required that the principal and the

he agent(s) sign at the same time,
nor that multiple agents sign at thee same time.

m
a
S

I/we, __________________________,
___,, have read the foregoing Power of
_____________
Attorney. I am/we
we are the person(s) identified therein as agent(s) for tthe
principal named therein.
I/we acknowledge my/our legal respons
responsibilities.
Agent(s) sign(s) here: =>
=>

STATE OF NEW YORK

e
l
p

) ss.:
COUNTY OF _________

m
a

On the _____ day of _____, inn the year 20___, before me,
me the
th
undersigned, a Notary
appeared
perso
otary Publicc in and for said state, personally
appeare
______ ____________________,
to
_________, personally known to me or proved
__________________,
pro
me onn the basis off satisfactory evidence to be the person w
whose name is
acknowledged
to me that he/she
ackno
subscribedd to the within instrument and acknowledge
executed the same in his/her capacity, and that
tha by his/her signature on
he instrument, the person or tthe entity uupon behalf of which the person
the
instrument.
acted executed the instru

_______________________________
__________
Notary Public
P

STATE OF NEW YORK

e
l
p

)
) ss.:

COUNTY OF _________

m
a

On the ____ day off ______, in the year _____, before m

me, the
undersigned,
personally appeared
signed, a Notary Public in and for said state, persona
_____ ________, personally known to me or proved to me on the basis
pers whose nname is subscribed to the
of satisfactory evidence to be the person
acknowle
within instrument and acknowledged
to me
m that he/she executed the same
his/her signature on the instrument, the
in his/her capacity, and tthat by his
upon behalf
erson or the entity
e
person
beh of which the person acted executed the
instrument.
strument.

_______________________________
Notary Public

(p) SUCCESSOR AGENT'S SIGNATURE AND

ACKNOWLEDGMENT OF APPOINTMENT:

e
l
p
m

It is not required that the principal and the Successor

agent(s), if any,
sor agent(s)
sign at the same time, nor that multiple Successor
or agents sign at the
sor
th same
time. Furthermore, successor agents cannot
Attorney
nnot usee this Power of Att
unless the agent(s) designated above
serve.
ve is/are unable or unwilling to ser
serv
I/We, __________________,
ad the foregoing Power of Attorney.
Att
_____, have read
Attorney
I am/We are the person(s) identified
entified therein as Successor agent(s) for tthe
principal named therein.
ein.

a
S

>
Successor Agent(s
Agent(s) sign(s) here: =>

STATE OF NEW YORK

STA

COUNTY OF _________

=>

e
l
p

) ss.:
)

On the _________ day of ________________,

_____, in the year _________,
_______________,
before me, the undersigned,
otary Public in and for said state,
s
gned, a Notary
personally appearedd _____________________,
known to me or
______________, personally know
proved to mee on the basiss of satisfactory evidence to be the person whose
name is subscribed
to me that
ed to the within instrument and acknowledged
ackn
acknowledg
that by his/her
a
he/she executed the same in his/her capacity, and
an
entity upon behalf of which
perso or the en
signature on the instrument, the person
in
the person acted executed the instrument.

m
a

_______________________________
______________
Notary
ary Public

STATE OF NEW YORK

e
l
p

) ss.:
COUNTY OF _________

m
a

On the ________ day

_________, in the year _________,
_____
y of _______________,
________
before me, the undersigned,, a Notary Public in and for said stat
state,
personally appeared ___________________,
__________________, personally known to me or
proved
whose
ed to me on thee basis of satisfactory evidence to be the person
p
acknowledged to me that
ubscribed to the within instrument and ackno
name is subscribed
and that by his/her
capac
he/she executed the same in his/her capacity,
capaci
ignature on the instrument, the person or the entity upon behalf of which
signature
execute the instrument.
the person acted executed
instru

_______________________________
__________
Notary Public
P

m
a

e
l
p