Power of Attorney

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       Notice to the Principal: As the “Principal,” you are using this Durable
Power of Attorney to grant power to another person (called the “Agent” or
“Attorney in Fact”) to make decisions, including, but not limited to, decisions
concerning your money, property, or both, and to use your money, property,
or both on your behalf. If this written Durable Power of Attorney does not
limit the powers that you give to your Agent, your Agent will have broad and
sweeping powers to sell or otherwise dispose of your property, and to spend
your money without advance notice to you or approval by you. Under this
document, your agent will continue to have these powers after you become
incapacitated, and unless otherwise indicated your agent will have these
powers before you become incapacitated. You have the right to retain this
Power and not to release this power until you instruct your attorney or any
other person who may hold this Power of Attorney to release it to your Agent
pursuant to written instructions. You have the right to revoke or take back
the Durable Power of Attorney at any time, so long as you are of sound mind.
 If there is anything about this Durable Power of Attorney that you do not
understand, you should seek professional advice.

___________________________                 ______________________________
Witness                                     JANE DOE


                         DURABLE POWER OF ATTORNEY

       I, JANE W. DOE, of                                        ,                  , State
of                        , in consideration of the confidence I have in JOHN B. SMITH, of
                          ,                       , State of                        , do
hereby appoint JOHN B. SMITH my true and lawful agent and Attorney-In-Fact for me and in
my name, place and stead:

       1.    To sign checks on all accounts or any other funds standing in my name and to
withdraw funds from said accounts;

       2.     To make any and all applications for governmental, public or private benefits to
which I may be entitled;

        3.     To execute, endorse, accept or deliver any and all bills of exchange, checks, drafts
or other papers in connection with my affairs;

       4.     To make either partial or total withdrawals of my money which I may have in any
savings bank, national bank or trust company, wherever situated, and to sign any necessary
orders to withdraw the same for me and in my name, and to do all other things necessary to
enable withdrawal of said money;

       5.      To consent for me to receive medical or other professional care, counsel,
treatment or services and to withdraw such consent;

        6.     To bargain, contract, purchase, receive and take lands, tenements, hereditaments
or to accept the seizing and possession of lands and deeds, or to lease, demise, bargain, sell,
release, convey, or mortgage any lands, tenements and hereditaments upon such terms and
conditions and under such covenants as my said Attorney shall think fit and also for me and in
my name, and as my acts and deeds, to sign, seal, execute and deliver or acknowledge such
deeds, leases and assignments of leases, covenants, indentures, agreements, mortgages, Bills of
Lading, bills, bonds, notes, receipts, evidences of debt releases and satisfaction of mortgages,
judgments, or other debts, or such other instruments in writing of whatsoever kind and nature as
may be necessary or proper in the premises;

       7.       To exercise or perform any act, power, duty, right, or obligation whatsoever that I
now have, or may hereafter acquire the legal right, power, or capacity to exercise or perform, in
connection with, arising from, or relating to any person, item, transaction, thing, business
property, real or personal, tangible or intangible, or any matter whatsoever;

       8.      To have full access to any safe deposit box rented in my name, to remove the
contents and surrender the box. In reference to any safety deposit box, JOHN SMITH shall have
a continued right of access to any safety deposit box notwithstanding my death, and the written

consent of the State of                       Department of Revenue Administration shall not be
required for the removal of contents of such box in whole or in part;

       9.      To transfer all or any part of my assets, real or personal, tangible or intangible to
any revocable trust which is in existence, or which I may now or in the future create;

        10.    To give any of my assets to persons of natural affection, having in mind the
objective of such gifts being the qualification for state or federal medical, welfare or such
assistance programs for my benefit, or for the reduction of state and/or federal estate or
inheritance taxes on my estate;

        11.      To make out and execute all returns which may be required for the purpose of
determining income, employment, excise, gift, real estate or other taxes imposed by the United
States government or by any state or local government; to receive notices and information and to
perform all acts that I can perform including the power to pay all state and local taxes required by
law; to receive, endorse, and deposit refund checks, and file all claims for abatement, refund or
other papers relating thereto; and to execute Power of Attorney forms on my behalf (including,
but not limited to, Internal Revenue Service Form 2848: Power of Attorney and Declaration of
Representative, and State of                                   Department of Revenue
Administration Form for any federal income, employment, excise and gift tax and any state or
local tax relating to any and all tax years and tax forms. To purchase United States treasury
bonds of any type, including so-called discount bonds, flower bonds or bonds eligible for
redemption at par in payment of any estate taxes.

         12.     I hereby give and grant to said Attorney, JOHN B. SMITH, full power and
authority to do and perform all things described in this document and I hereby ratify and confirm
all that said Attorney, JOHN B. SMITH lawfully do or cause to be done by virtue thereof.

       13.    This durable power of attorney shall not be affected by my subsequent disability
or incompetence.

       14.     This Power of Attorney shall continue in effect until revoked by me in writing.

       IN WITNESS WHEREOF, I have hereunto set my hand and seal this _____ day of
                  , 20___.

___________________________                           ______________________________
Witness                                               JANE W. DOE


COUNTY OF                                                            , 20__

       Then personally appeared the above named, JANE W. DOE, and acknowledged the
foregoing to be her free act and deed.

      Before me,

                                     Justice of the Peace/Notary Public
                                     My Commission Expires:____________

                         AGENT’S ACKNOWLEDGEMENT

        I, JOHN B. SMITH, have read the attached Power of Attorney and am the person
identified as the Agent for the Principal, JANE W. DOE. I hereby acknowledge that when I act
as Agent or “attorney in fact,” I am given power under this Durable Power of Attorney to make
decisions about money, property, or both belonging to the Principal, and to spend the Principal’s
money, property, or both on the principal’s behalf, in accordance with the terms of this Durable
Power of Attorney.

       This Durable Power of Attorney is valid only if the principal is of sound mind when the
Principal signs it. When acting in the capacity of Agent, I am under a duty (called a “fiduciary
duty”) to observe the standards observed by a prudent person, which means the use of those
powers that is reasonable in view of the interests of the Principal and in view of the way in which
a person of ordinary judgment would act in carrying out that person’s own affairs. If the exercise
of my acts is called into question, the burden will be upon me to prove that I acted under the
standards of a fiduciary.

        As the Agent, I am not entitled to use the money or property for my own benefit or to
make gifts to myself or others unless the Durable Power of Attorney specifically gives me the
authority to do so. As the Agent, my authority under this Durable Power of Attorney will end
when the principal dies and I will not have authority to manage or dispose of any property or
administer the estate unless I am authorized to do so by a New Hampshire Probate Court.

       If I violate my fiduciary duty under this Durable Power of Attorney, I may be liable for
damages and may be subject to criminal prosecution. If there is anything about this Durable
Power of Attorney, or my duties under it, that I do not understand, I understand that I should seek
professional advice.

       Signed this _____ day of                      , 20___.

___________________________                  ____________________________________
Witness                                      JOHN B. SMITH


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Description: Power of Attorney