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KNOW ALL MEN BY THESE PRESENTS that I, ______________________________(donor or principal - person giving power of attorney), residing at ____________________________ (address), being of sound mind and legal capacity, do hereby make and appoint ______________________(agent, donee or attorney in fact - person receiving power of attorney), of ________________________(address), my true and lawful attorney-in-fact (agent), to act in my name and place, and for my use and benefit to do on my behalf anything that I can lawfully do by an attorney. Including: Authorize payment of bills; Run my business; Buy, manage and sell property; Control my investments; Prepare and file my taxes; Conduct banking transactions; Enter safety deposit boxes; Handle legal claims; Handle government issues; Make gifts; Make financial and estate planning decisions; Collect Social Security and other benefits; Settle claims; Employ professional assistance; Make transfers to revocable living trusts; and Collect debts. This Power of Attorney shall be effective on the date of ____________, 20___. And shall not be affected by my disability or mental incompetency, except as may be provided otherwise by an applicable state statute governed by the laws of the state of __________________. I may revoke this Power of Attorney at any time by providing written notice to my Agent. _______________________________________ Principal's Signature ______/______/_________ Date Agreed to and accepted by: _______________________________________ Agent's Signature ______/______/_________ Date WITNESSES: We know the principal personally and we believe him/her to be at least 18 years of age and of sound mind. This document was signed in our presence. The principal appears to be of

sound mind, and to be making this designation voluntarily, without duress, fraud or undue influence. Witness 1: Name _______________________________________________ Address _____________________________________________ Signature _______________________ Date ____/____/______ Witness 2: Name _______________________________________________ Address _____________________________________________ Signature _______________________ Date ____/____/______ Subscribed and sworn to before me on this _____ day of _________________, 20_____. ________________________________________ Notary's Signature

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