Special Power of Attorney
I, ___________(1)___________, of __________(2)_________, hereby appoint ______________(3)________________ of ___________(4)_______________, as my attorney in fact to act in my capacity to do any and all of the following: (DESCRIBE THE EXTENT OF AUTHORITY YOU ARE GIVING TO YOUR ATTORNEY-IN-FACT) The rights, powers, and authority of my attorney in fact to exercise any and all of the rights and powers herein granted shall commence and be in full force and effect on ____________(5)_______, 19__(6)_, and shall remain in full force and effect until ___________(7)_______________ or unless specifically extended or rescinded earlier by either party. Dated _____(8)____, 19__(9)_. ____________(10)______________
STATE OF _______(11)____________ COUNTY OF ______(12)____________ BEFORE ME, the undersigned authority, on this _(13)_ day of _______(14)________, 19_(15)_, personally appeared ___________(16)___________ to me well known to be the person described in and who signed the Foregoing, and acknowledged to me that he executed the same freely and voluntarily for the uses and purposes therein expressed. WITNESS my hand and official seal the date aforesaid. _________(17)___________________ NOTARY PUBLIC My Commission Expires:__(18)____