Durable Power of Attorney for Property, Finances, and Health Care (Florida)

GENERAL DURABLE POWER OF ATTORNEY

Finances, Property, and Health Care

(Florida Statutes 709.2101 et seq.)

STATE OF FLORIDA

COUNTY OF

KNOW ALL MEN BY THESE PRESENTS:

That whose address is “Principal”, execute this General Durable Power of Attorney and do hereby make, constitute and appoint: whose address is as my true and lawful agent and attorney in fact.

Without intending in any manner to limit or diminish the foregoing powers granted to my agent, but intending to expand or enlarge upon the same, I specifically authorize and empower my agent, to:

1. Forgive, request, demand, sue for, collect, receive, hold, purchase, invest and re-invest in, transfer, sell, convey, pledge all sums of money, dues, commercial paper, checks, drafts, deposits, legacies, bequests, devises, notes, interest, stock certificates, bonds, dividends, certificates of deposit, annuities, pension, profit sharing, retirement, social security, disability, insurance and other contractual benefits and proceeds, all documents of title, all property, real or personal, intangible and tangible property and property rights, and demands whatsoever;

2. Make, execute and deliver, in my name and on my behalf, instruments of conveyance covering real, personal or mixed properties owned or claimed by me;

3. Manage, maintain, repair, improve, invest, insure, rent, lease, encumber, and in any manner deal with any real or personal property owned by me;

4. Receive, deposit, withdraw, and endorse checks and drafts, and conduct financial institution transactions on my behalf;

5. Have access to safe deposit boxes and remove or dispose of contents therein;

6. Execute contracts, tax returns, declarations, and related forms on my behalf;

7. Acquire, purchase, exchange, buy or sell options to buy or sell and convey real or personal property;

8. Health care: Execute medical insurance forms and make health care decisions for me if I am unable to give informed consent;

9. Operate any business or corporation on my behalf;

10. Commence, prosecute, discontinue or defend legal proceedings relating to my affairs;

11. Borrow money and execute promissory notes and security instruments;

12. Engage, employ and dismiss agents, servants, advisors, including accountants and attorneys;

13. Receive distributions from trusts and withdraw trust assets held for my benefit;

14. Hold, purchase or invest in wasting or unproductive assets;

15. This instrument shall be construed as a general durable power of attorney under Florida law;

16. Third parties may rely upon the representations of the agent as to all powers granted hereunder.

The following powers are specifically granted to my attorney-in-fact (principal must initial any powers wished to be granted below):

(a) Create an inter vivos trust;

(b) Amend, modify, revoke, or terminate a trust if expressly permitted;

(c) Make a gift;

(d) Create or change rights of survivorship;

(e) Create or change a beneficiary designation;

(f) Waive right to be a beneficiary of a joint and survivor annuity;

(g) Disclaim property and powers of appointment;

(h) Authority to conduct investment transactions;

(i) Authority to conduct banking transactions;

Notwithstanding the foregoing, the attorney in fact may not:

1. Perform duties under a contract that requires the exercise of personal services of the principal;

2. Make any affidavit as to the personal knowledge of the principal;

3. Vote in any public election on behalf of the principal;

4. Execute or revoke any will or codicil for the principal;

5. Create, amend, modify, or revoke any document or other disposition effective at the principal's death unless expressly authorized;

6. Exercise powers and authority granted to the principal as trustee or as court-appointed fiduciary.

I direct that the above-related powers and authority of my said agent shall be effective regardless of any mental or physical incapacity on my part.

And I do hereby undertake to ratify and confirm all acts performed by my said agents, acting in my name and on my behalf.

INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH:

A. General Grant of Power and Authority. Subject to any limitations in this Directive, my agent has the power and authority to request, review, receive, execute releases, consent to disclosure, and consent to donation of organs for medical purposes.

B. HIPAA Release Authority. My agent shall be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records.

This release authority applies to any information governed by HIPAA, and I authorize covered health care providers to give, disclose and release to my agent, without restriction, all of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition.

The authority given my agent has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my health care provider.

NOTICE TO PERSON EXECUTING THIS DOCUMENT

This is an important legal document. Before executing this document, you should know these important facts:

This document gives the person you designate as the attorney-in-fact the power to make health care decisions for you when you are unable to give informed consent.

Except as otherwise specified, this document gives your agents the power to consent to your doctor not giving treatment or stopping treatment necessary to keep you alive.

This durable power of attorney is not affected by subsequent incapacity of the principal except as provided by Florida Statutes.

The attorney in fact must be a natural person who is 18 years or older and of sound mind, or a financial institution authorized to conduct trust business in Florida.

Notwithstanding this document, you have the right to make medical and other health care decisions for yourself so long as you can give informed consent.

The document gives your agents authority to consent, refuse consent, or withdraw consent to any care, treatment, service or procedure to maintain, diagnose or treat a physical or mental condition.

You have the right to revoke the authority of your agents by notifying them or your treating provider in writing.

Your agents have the right to examine your medical records and to consent to this disclosure unless you limit this right in this document.

Unless you otherwise specify, this document gives your agents the power after you die to authorize an autopsy, donate your body or parts, and direct the disposition of your remains.

IN WITNESS WHEREFORE, I have executed this General Durable Power of Attorney consisting of pages this the day of , 20 .

ATTESTATION

The witnesses declare under penalty of perjury that the principal signed and acknowledged this durable power of attorney in our presence and that we are qualified witnesses under Florida law.

Witness our signatures, this the day of , 20 .

WITNESSES:

NOTARY ACKNOWLEDGMENT

State of Florida, County of

The foregoing instrument was acknowledged before me this

By who is/are personally known to me or has produced as identification.