Fill and Sign the Durable General Power of Attorney Effective at a Future Time Aka Springing Power of Attorney New York Form

DURABLE GENERAL POWER OF ATTORNEY EFFECTIVE AT A FUTURE TIME THE POWERS YOU GRANT BELOW CONTINUE TO BE EFFECTIVE SHOULD YOU BECOME DISABLED OR INCOMPETENT CAUTION TO THE PRINCIPAL: YOUR POWER OF ATTORNEY IS AN IMPORTANT DOCUMENT. AS THE "PRINCIPAL," YOU GIVE THE PERSON WHOM YOU CHOOSE (YOUR "AGENT") AUTHORITY TO SPEND YOUR MONEY AND SELL OR DISPOSE OF YOUR PROPERTY DURING YOUR LIFETIME WITHOUT TELLING YOU. YOU DO NOT LOSE YOUR AUTHORITY TO ACT EVEN THOUGH YOU HAVE GIVEN YOUR AGENT SIMILAR AUTHORITY. WHEN YOUR AGENT EXERCISES THIS AUTHORITY, HE OR SHE MUST ACT ACCORDING TO ANY INSTRUCTIONS YOU HAVE PROVIDED OR, WHERE THERE ARE NO SPECIFIC INSTRUCTIONS, IN YOUR BEST INTEREST. "IMPORTANT INFORMATION FOR THE AGENT” AT THE END OF THIS DOCUMENT DESCRIBES YOUR AGENT'S RESPONSIBILITIES. YOUR AGENT CAN ACT ON YOUR BEHALF ONLY AFTER SIGNING THE POWER OF ATTORNEY BEFORE A NOTARY PUBLIC. YOU CAN REQUEST INFORMATION FROM YOUR AGENT AT ANY TIME. IF YOU ARE REVOKING A PRIOR POWER OF ATTORNEY BY EXECUTING THIS POWER OF ATTORNEY, YOU SHOULD PROVIDE WRITTEN NOTICE OF THE REVOCATION TO YOUR PRIOR AGENT(S) AND TO THE FINANCIAL INSTITUTIONS WHERE YOUR ACCOUNTS ARE LOCATED. YOU CAN REVOKE OR TERMINATE YOUR POWER OF ATTORNEY AT ANY TIME FOR ANY REASON AS LONG AS YOU ARE OF SOUND MIND. IF YOU ARE NO LONGER OF SOUND MIND, A COURT CAN REMOVE AN AGENT FOR ACTING IMPROPERLY. YOUR AGENT CANNOT MAKE HEALTH CARE DECISIONS FOR YOU. YOU MAY EXECUTE A "HEALTH CARE PROXY" TO DO THIS. THE LAW GOVERNING POWERS OF ATTORNEY IS CONTAINED IN THE NEW YORK GENERAL OBLIGATIONS LAW, ARTICLE 5, TITLE 15. THIS LAW IS AVAILABLE AT A LAW LIBRARY, OR ONLINE THROUGH THE NEW YORK STATE SENATE OR ASSEMBLY WEBSITES, WWW.SENATE.STATE.NY.US OR WWW.ASSEMBLY.STATE.NY.US. IF THERE IS ANYTHING ABOUT THIS DOCUMENT THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. THIS is intended to constitute a POWER OF ATTORNEY EFFECTIVE AT A FUTURE TIME pursuant to Article 5, Title 15 of the New York General Obligations Law: I, _____________________________________________________________________ (Insert your name and address) Do hereby appoint: ______________________________________________________________________________ (If 1 person is to be appointed agent, insert the name and address of your agent above) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (If 2 or more persons are to be appointed agents by you, insert their names and addresses above) my attorney(s)-in-fact TO ACT (If more than one agent is designated, CHOOSE ONE of the following two choices by putting your initials in ONE of the blank spaces ( ) to the left of your choice :) ( ) Each agent may SEPARATELY act. ( ) All agents must act TOGETHER. (If neither blank space is initialed, the agents will be required to act TOGETHER) TO TAKE EFFECT upon the occasion of the signing of a written statement EITHER: (INSTRUCTIONS: COMPLETE OR OMIT SECTION (I) --OR-- SECTION (II) BELOW BUT NEVER COMPLETE BOTH SECTIONS (I) AND (II) BELOW. IF YOU DO NOT COMPLETE EITHER SECTION (I) OR SECTION (II) BELOW, IT SHALL BE PRESUMED THAT YOU WANT THE PROVISIONS OF SECTION (I) BELOW TO APPLY) (I) by a physician or physicians named herein by me at this point: Dr. __________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (Insert Full Name(s) and Address(es) of Certifying Physician(s) Chosen by You) or if no physician or physicians are named hereinabove, or if the physician or physicians named hereinabove are unable to act, by my regular physician, or by a physician who has treated me within one year preceding the date of such signing, or by a licensed psychologist or psychiatrist, certifying that I am suffering from diminished capacity that would preclude me from conducting my affairs in a competent manner; --OR-- (II) By a person or persons named herein by me at this point: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (Insert Full Name(s) and Address(es) of Certifying Person(s) Chosen by You) CERTIFYING that the following specified event has occurred: ______________________________________________________________________________ ______________________________________________________________________________ (Insert hereinabove the specified event the certification of which will cause THIS POWER OF ATTORNEY to take effect) IN MY NAME, PLACE AND STEAD in any way which I myself could do, if I were personally present, with respect to the following matters as each of them is defined in Title 15 of Article 5 of the New York General Obligations Law to the extent that I am permitted by law to act through an agent: (DIRECTIONS: Initial in the blank space to the left of your choice any one or more of the following lettered subdivisions as to which you WANT to give your agent authority. If the blank space to the left of any particular lettered subdivision is NOT initialed, NO AUTHORITY WILL BE GRANTED for matters that are included in that subdivision. ALTERNATIVELY, the letter corresponding to each power you wish to grant may be written or typed on the blank line in subdivision "(P)", and you may then put your initials in the blank space to the left of subdivision "(P)" in order to grant each of the powers so indicated) (_____) (A) real estate transactions; (_____) (B) chattel and goods transactions; (_____) (C) bond, share and commodity transactions; (_____) (D) banking transactions; (_____) (E) business operating transactions; (_____) (F) insurance transactions; (_____) (G) estate transactions; (_____) (H) claims and litigation; (_____) (I) personal relationships and affairs; (_____) (J) benefits from governmental programs or civil or military service; (_____) (K) health care billing and payment matters; records, reports, and statements; (_____) (L) retirement benefit transactions; (_____) (M) tax matters; (_____) (N) all other matters; (_____) (O) full and unqualified authority to my agent(s) to delegate any or all of the foregoing powers to any person or persons whom my agent(s) select; (_____) (P) EACH of the matters identified by the following letters ______ . (Special provisions and limitations may be included in the statutory short form durable power of attorney only if they conform to the requirements of section 5-1503 of the New York General Obligations Law.) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ This durable Power of Attorney shall not be affected by my subsequent disability or incompetence. If every agent named above is unable or unwilling to serve, I appoint ______________________________________________________________________________ (Insert name and address of successor) To be my agent for all purposes hereunder. TO INDUCE ANY THIRD PARTY TO ACT HEREUNDER, I HEREBY AGREE THAT ANY THIRD PARTY RECEIVING A DULY EXECUTED COPY OR FACSIMILE OF THIS INSTRUMENT MAY ACT HEREUNDER, AND THAT REVOCATION OR TERMINATION HEREOF SHALL BE INEFFECTIVE AS TO SUCH THIRD PARTY UNLESS AND UNTIL ACTUAL NOTICE OR KNOWLEDGE OF SUCH REVOCATION OR TERMINATION SHALL HAVE BEEN RECEIVED BY SUCH THIRD PARTY, AND I FOR MYSELF AND FOR MY HEIRS, EXECUTORS, LEGAL REPRESENTATIVES AND ASSIGNS, HEREBY AGREE TO INDEMNIFY AND HOLD HARMLESS ANY SUCH THIRD PARTY FROM AND AGAINST ANY AND ALL CLAIMS THAT MAY ARISE AGAINST SUCH THIRD PARTY BY REASON OF SUCH THIRD PARTY HAVING RELIED ON THE PROVISIONS OF THIS INSTRUMENT. THIS GENERAL POWER OF ATTORNEY EFFECTIVE AT A FUTURE TIME MAY BE REVOKED BY ME AT ANY TIME. In Witness Whereof I have hereunto signed my name this ________ day of _________________________ , 20 ______ . (YOU SIGN HERE :) ==> __________________________________________ (Signature of Principal) POWER OF ATTORNEY NEW YORK STATUTORY MAJOR GIFTS RIDER AUTHORIZATION TO MAKE MAJOR GIFTS OR OTHER TRANSFERS CAUTION TO THE PRINCIPAL: This OPTIONAL rider allows you to authorize your agent to make major gifts or other transfers of your money or other property during your lifetime. Granting any of the following authority to your agent gives your agent the authority to take actions which could significantly reduce your property or change how your property is distributed at your death. "Major gifts or other transfers” are described in section 5-1514 of the General Obligations Law. This Major Gifts Rider does not require your agent to exercise granted authority, but when he or she exercises this authority, he or she must act according to any instructions you provide, or otherwise in your best interest. This Major Gifts Rider and the Power of Attorney it supplements must be read together as a single instrument. Before signing this document authorizing your agent to make major gifts and other transfers, you should seek legal advice to ensure that your intentions are clearly and properly expressed. (a) GRANT OF LIMITED AUTHORITY TO MAKE GIFTS Granting gifting authority to your agent gives your agent the authority to take actions which could significantly reduce your property. If you wish to allow your agent to make gifts to himself or herself, you must separately grant that authority in subdivision (c) below. To grant your agent the gifting authority provided below, initial the bracket to the left of the authority. ( ) I grant authority to my agent to make gifts to my spouse, children and more remote descendants, and parents, not to exceed, for each donee, the annual federal gift tax exclusion amount pursuant to the Internal Revenue Code. For gifts to my children and more remote descendants, and parents, the maximum amount of the gift to each donee shall not exceed twice the gift tax exclusion amount, if my spouse agrees to split gift treatment pursuant to the Internal Revenue Code. This authority must be exercised pursuant to my instructions, or otherwise for purposes which the agent reasonably deems to be in my best interest. (b) MODIFICATIONS: Use this section if you wish to authorize gifts in excess of the above amount, gifts to other beneficiaries or other types of transfers. Granting such authority to your agent gives your agent the authority to take actions which could significantly reduce your property and/or change how your property is distributed at your death. If you wish to authorize your agent to make gifts or transfers to himself or herself, you must separately grant that authority in subdivision (c) below. ( ) I grant the following authority to my agent to make gifts or transfers pursuant to my instructions, or otherwise for purposes which the agent reasonably deems to be in my best interest. (c) GRANT OF SPECIFIC AUTHORITY FOR AN AGENT TO MAKE MAJOR GIFTS OR OTHER TRANSFERS TO HIMSELF OR HERSELF: (OPTIONAL) If you wish to authorize your agent to make gifts or transfers to himself or herself, you must grant that authority in this section, indicating to which agent(s) the authorization is granted, and any limitations and guidelines. ( ) I grant specific authority for the following agent(s) to make the following major gifts or other transfers to himself or herself: This authority must be exercised pursuant to my instructions, or otherwise for purposes which the agent reasonably deems to be in my best interest. (d) ACCEPTANCE BY THIRD PARTIES: I agree to indemnify the third party for any claims that may arise against the third party because of reliance on this Major Gifts Rider. (e) SIGNATURE OF PRINCIPAL AND ACKNOWLEDGMENT: In Witness Whereof I have hereunto signed my name on ___________________ , 20 ______ . PRINCIPAL signs here: ________________________________ (Acknowledgement) (f) SIGNATURES OF WITNESSES: By signing as a witness, I acknowledge that the principal signed the Major Gifts Rider in my presence and the presence of the other witness, or that the principal acknowledged to me that the principal’s signature was affixed by him or her or at his or her direction. I also acknowledge that the principal has stated that this Major Gifts Rider reflects his or her wishes and that he or she has signed it voluntarily. I __________________________ am not named herein as a permissible recipient of major gifts. ___________________________ _________________________ Signature of witness 1 Signature of witness 2 __________________________ __________________________ Date Date __________________________ __________________________ Print name Print name __________________________ __________________________ Address Address __________________________ __________________________ City, State, Zip code City, State, Zip code (g) This document prepared by: __________________________ IMPORTANT INFORMATION FOR THE AGENT: When you accept the authority granted under this Power of Attorney, a special legal relationship is created between you and the principal. This relationship imposes on you legal responsibilities that continue until you resign or the Power of Attorney is terminated or revoked. You must: (1) Act according to any instructions from the principal, or, where there are no instructions, in the principal's best interest (2) Avoid conflicts that would impair your ability to act in the principal's best interest; (3) Keep the principal’s property separate and distinct from any assets you own or control, unless otherwise permitted by law; (4) Keep a record or all receipts, payments, and transactions conducted for the principal; and (5) Disclose your identity as an agent whenever you act for the principal by writing or printing the principal's name and signing your own name as "agent" in either of the following manner: (Principal's Name) by (Your Signature) as Agent, or (your signature) as Agent for (Principal's Name). You may not use the principal's assets to benefit yourself or give major gifts to yourself or anyone else unless the principal has specifically granted you that authority in this Power of Attorney or in a Statutory Major Gifts Rider attached to this Power of Attorney. If you have that authority, you must act according to any instructions of the principal or, where there are no such instructions, in the principal’s best interest. You may resign by giving written notice to the principal and to any co-agent, successor agent, monitor if one has been named in this document or the principal's guardian if one has been appointed. If there is anything about this document or your responsibilities that you do not understand, you should seek legal advice. Liability of agent: The meaning of the authority given to you is defined in New York’s General Obligations Law, Article 5, Title 15. If it is found that you have violated the law or acted outside the authority granted to you in the Power of Attorney, you may be liable under the law for your violation. (o) AGENT'S SIGNATURE AND ACKNOWLEDGMENT OF APPOINTMENT: It is not required that the principal and the agent(s) sign at the same time, nor that multiple agents sign at the same time. We, _______________________________ read the foregoing Power of Attorney. I am/we are the person(s) identified therein as agent(s) for the principal named therein. I/we, _______________________________ , have read the foregoing Power of Attorney. I am/we are the person(s) identified therein as agent(s) for the principal named therein. I/we acknowledge my/our legal responsibilities. Agent(s) sign(s) here: _______________________________ ___________________________________ ACKNOWLEDGEMENT State of New York County of _____________________ On the __________ day of ___________________ in the year ________ before me, the undersigned, personally appeared __________________________________________________ _____________________________________________________ , personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument. ________________________________________________ (Signature and office of individual taking Acknowledgement.) SPECIAL NOTES: 1. The execution of power of attorney effective at a future time shall be duly acknowledged by the principal in the manner prescribed for the acknowledgement of a conveyance of real property. 2. No provision of this article shall be construed to bar the use of any other or different form of power of attorney desired by the parties concerned. 3. Every power of attorney effective at a future time, to be valid, must be written, typed or printed using letters which are in legible writing of or clear type of no less than twelve-point in size or if in writing a reasonable equivalent thereof and must contain, in bold face upper case or upper and lower case type or a reasonable equivalent thereof the "CAUTION" which is printed in bold face type at the beginning of the statutory form printed above and the "DIRECTIONS" which are printed in bold face type immediately before subdivisions (A) through (Q) of the statutory form printed above.