Fill and Sign the City State Zip 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 OHIOCOUNTY 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.
........................................... 1. In the event, I become incapacitated or deceased, to provide medical care pursuant to a court order, my estate shall pass to my personal attorney-in-fact, if his or her name or address and phone number is on an official California health registry. I also authorize my personal attorney-in-fact to take my property upon my death. 2. In these events, my estate to be administered by my personal attorney-in-fact and if not designated by name, to be administered by the administrator as stated below as if my attorney-in-fact name was on a California health registry. (please make sure your name and address are on this California health registry) name: ............................... Address: city: ........ State : ........ County : ..................... Zip: phone: 4) .............................. (add an entry when you change attorneys-in-fact) attorney address: ..................... Phone: 4. ................................................... I authorize all actions necessary to carry out my duties as attorney in-fact. My duties include: ........................................................ ................................................... I understand that I am signing this form by personal responsibility only and that by signing below I am not authorizing other persons. I have been advised that this form binds me as an action of my own free will to the same extent as if I had signed it before. I consent to the jurisdiction and power of the courts of this state and of the United States of America to bind me by this document. ..................... Signature of my attorney in ......................................... Date of my attorney in fact ...................................... ................... [your signature] .................................................. Date of your attorney [your signature] ................................................... ....................................... Date of attorney attaining attornie in fact attornie in fact ................................................... Date of attorney attaining attorney attornie and attornie in fact ................................................... Date of attorney attaining attorney attornie attorn in fact ............................................. Date of attorney attaining attorney attorn in fact ................................................... Date of attorney attaining attorney attorn in fact attorney in fact signature attorn in fact attorn in fact attorn in fact attorn in fact attorn in fact attorn form attorn form attorn form attorn form att.orn form att