Fill and Sign the Appointed and by These Presents Do Make Constitute and Appoint Form

Prepared by, recording requested by and return to:Name: _________________ _Company: _________________ _Address: _________________ _City: _________________ _State: _______ _Zip: _________Phone: _________________ _Fax: _________________ _----------------------Above this Line for Official Use Only--------------------- The information above is provided in the event this form is to be recorded. LIMITED POWER OF ATTORNEY STATE of VERMONTCOUNTY OF _________________ _ KNOW ALL MEN BY THESE PRESENT, THAT I _________________ _,whose address is _________________ _, _________________ _ (City), _________________ _ (State), ____________ (Zip), “Principal”, have made, constituted and appointed, and by these presents do make, constitute and appoint, _________________ _ my true and lawful attorney in fact to act with the following limited powers, to wit: Insert powers here. See examples at the end of this form_________________ ___________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ FURTHER, I do authorize my aforesaid attorney-in-fact to execute, acknowledge and deliver any instrument under seal or otherwise, and to do all things necessary to carry out the intent hereof, hereby granting unto my said attorney-in-fact full power and authority to act in and concerning the premises as fully and effectually as I may do if personally present, limited, however, to the purpose for which this limited power of attorney is executed.PROVIDED, however, that all business transacted hereunder for me or for my account shall be transacted in my name, and that all endorsements and instruments executed by my said attorney-in-fact for the purpose of carrying out the foregoing powers shall contain my name, followed by that of my said attorney and the designation "attorney-in-fact".I further declare that any act or thing lawfully done hereunder and within the powers herein stated by my said attorney shall be binding on myself and my heirs, legal and personal representatives and assigns, whether the same shall have been done either before or after my death, or other revocation of this instrument, unless and until reliable intelligence or notice thereof shall have been received by my said attorney.This Power of Attorney shall be:( ) Non-Durable.( ) Durable and shall not be affected by any subsequent disability or incompetence.Third parties may rely upon the representations of the agents as to all matters relating to any power granted to them hereunder, and no person who may act in reliance upon the representations of the agent or the authority granted to it shall incur any liability to the principal or his estate as result of permitting the agent to exercise any power. IN WITNESS WHEREOF, I have hereunto set my hand and seal this the _____ day of _________________ _, 20____. Signed this _______ day of _________________ _ , 20________ ______________________________________________ Principal_________________ _City, County, and State of ResidenceI, _________________ _, witnessed the signature of the principal above and I affirm that the principal appeared to be of sound mind and free from duress at the time this power of attorney was signed and the principal affirmed to me that he or she was aware of the nature of the document and signed it freely and voluntarily. Witness: ______________________________________________________________________ Address: _________________ _Witness: ______________________________________________________________________ Address: _________________ _STATE OF VERMONTCOUNTY OF _________________ _ At _________________ _ (town or city) on _________________ _ (date) _________________ _ personally appeared and acknowledged the foregoing power of attorney to be his/her free act and deed. Before me- ___________________________________________ (Seal)(Signature of Person Taking Acknowledgment)_________________ _ (Title)My commission expires: _________________ _I, _________________ _, agent named above attest that : (1) I accept appointment as agent; (2) I understand the duties I am assuming under this power of attorney under the law; (3) I understand that I have a duty to act if expressly required to do so in this power of attorney consistent with said 14 VSA Section 3506(c); and (4) I understand that I am expected to use my special skills or expertise on behalf of the principal as follows (insert any such special skills): Date_________________ _ _________________ _ Agent Principal Name and AddressAttorney-in-Fact Name and AddressName: _________________ _Name: _________________ _Address: _________________ _Address: _________________ _City: _________________ _City: _________________ _State: ____________ Zip: __________ _State: ___________ Zip: ___________Phone: _________________ _Phone: _________________ _Witness Name and AddressWitness Name and AddressName: _________________ _Name: _________________ _Address: _________________ _Address: _________________ _City: _________________ _City: _________________ _State: ____ _ Zip: __________ _State: _____ _ Zip: ____________Phone: _________________ _Phone: _________________ _NOTICE: THESE ARE SAMPLE POWERS. Collection of Debts . To demand, collect, recover, sue for, receive and give receipt or release for any monies, debts, dividends, interests, royalties, legacies, annuities, demands, discounts, income, rents, profits, securities or other property of any sort, now or hereafter due or becoming due to me or to which I may be or hereafter become entitled. Endorsements. a) To endorse and negotiate for any and all purposes all promissory notes, bills of exchange, checks, drafts or other negotiable or non-negotiable paper payable to me or to my order; b) To endorse for transfer all certificates of stock, bond or other securities;c) To endorse and cash United States Savings Bonds and notes.Executing Government Vouchers. To execute vouchers in my behalf for any and all allowances, compensation and reimbursements properly payable to me by the Government of the United States or any agency or department thereof. Depositing Money and Other Property. To deposit in my attorney's or my name, or jointly in both our names, in any banking institution, funds or property, and to withdraw any part or all of my deposits at any time made by me in my behalf. Borrowing Money. To borrow money in my name when deemed necessary to my said attorney upon such terms as to my said attorney appear proper and to execute such instruments as may be requisite for such purpose. Acquisition of Property. To buy, receive, lease, accept or otherwise acquire in my name and for my account property, real, personal or mixed, upon such terms, considerations and conditions as my said attorney shall think proper. Recovering Possession of Property. To eject, remove or relieve tenants or other persons from, and recover possession of, any property, real, personal or mixed in which I now or hereafter may have an interest. Litigation. To institute, maintain, defend, compromise, arbitrate or otherwise dispose of, any and all actions, suits, attachments or other legal proceedings for or against me. Tax Returns. To prepare and execute any tax returns, including, but not limited to, Federal income tax returns, State income tax returns, Social Security tax returns, and Federal and State information and estimated returns; to execute any claims for refund, protests, applications for abatement, petitions to the United States Board of Tax Appeals or any other Board or Court, Federal or State, consents and waivers to determination and assessment of taxes and consents and waivers agreeing to a later determination and assessment of taxes than is provided by statute of limitations; to receive and endorse and collect any checks in settlement of any refund of taxes; to examine and to request and receive copies of any tax returns, reports and other information from the United States Treasury Department or any other taxing authority, Federal or State, in connection with any of the foregoing matters.Automobiles. To execute and deliver to the proper persons and authority any and all documents, instruments and papers necessary to effect proper registration of any automobile in which I now or may hereafter have an interest, or the sale thereof and transfer of legal title thereto as required by law, and to collect and receipt for all monies paid in consideration of such sale and transfer. Disposition of Property . To sell, assign, transfer, convey, exchange, deed, mortgage, pledge, lease, let, license, demise, remise, quitclaim, bargain or otherwise dispose of any or all of my real estate, stocks, bonds, evidences of indebtedness and other securities and other personal tangible and intangible or mixed property, or any custody, possession, interest or right therein at public or private sale, upon such terms, consideration, and conditions as my said attorney shall deem advisable and to execute, acknowledge and deliver such instruments and writings of whatsoever kind and nature as may be necessary, convenient or proper in the premises.