Fill and Sign the Durable Power of Attorney for Property Finances and Health Care Florida Form

Prepared by: ____________________________ After Recording, Return to: ____________________________ ____________________________ ____________________________ ____________________________ 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 , _____________________________________ (complete Name of Principal) , whose address is ______________________________________________________ (Street Address, City, State, Zip Code) “Principal”, execute this General Durable Power of Attorney and do hereby make, constitute and appoint: ________________________________________ (Full Name of Agent) , whose address is ________________________________________________ (Street Address, City, State, Zip Code) as my true and lawful agent and attorney in fact (hereinafter sometimes called "my agent"), with full power and authority TO ACT FOR ME, INDIVIDUALLY, AND IN MY NAME, PLACE AND STEAD , with reference to the transaction of any and all business, do any and all things, exercise any discretion, and execute and deliver any and all conveyances and other documents of whatsoever kind and character, in or about or with respect to any and all matters and things concerning me or my property, real or personal or mixed, or affairs, as fully and completely as I might lawfully do if present and acting in person with full power of substitution or revocation, and to have all powers and rights that I now possess or may possess hereafter with respect to all of my property. 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: General Durable Power of Attorney Page 1 of 8 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 (including "Bearer Bonds"), dividends, certificates of deposit, annuities (private and public), 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, liquidated, now or hereafter owned by me, or due, owning, payable or belonging to me or in which I have or may hereafter acquire an interest; 2. Make, execute and deliver, in my name and on my behalf, for any consideration whatsoever, for cash or on a deferred payment plan, instruments of conveyance covering real, personal or mixed properties owned or claimed by me, wherever situated, containing such terms, covenants and conditions deemed necessary or advisable by my agent; 3. Manage, maintain, repair, improve, invest, insure, rent, lease, encumber, and in any manner deal with any real or personal property owned by me, tangible or intangible, or any interest therein, that I now own or may hereafter acquire, in my name or for my benefit, enter into any lease agreement or contract for sale or repair of said property with the right to collect all rents or other funds which may be due from said property or properties, including but not limited to the execution of oil, gas and mineral leases, related contracts, agreements and division orders and collection of rents, bonuses and royalties on same, all upon such terms and conditions as my agent shall deem proper; 4. Receive, receipt for, deposit, withdraw and execute, and endorse checks and drafts thereon, in my name and on my behalf, from any bank or any other financial institution, or any investment or brokerage firm or credit union, funds, owned or claimed by me and which are on deposit in my name, including but not limited to negotiating certificates of deposit in my name in banks, savings and loan associations and other institutions and the execution of any papers or documents with the Federal Social Security Administration and/or any other governmental agency, county, state or federal; and to receive and receipt for every sum of money which is now or hereafter shall be due or belonging to me; 5. Have access at any time or times to any safe deposit box rented by me, wheresoever located, and open, enter into and remove, in my name and on my behalf, from any safe deposit box registered in my name, or jointly in my name, located in any bank or any other financial institution, all or any part of the property or contents contained therein, with the further right and power, in my name and on my behalf to sell or otherwise dispose of such property, and to surrender or relinquish said safe deposit box. Any institution in which any such box may be located shall not incur any liability to me or my estate as a result of permitting my agent to exercise this power; 6. Execute, in my name and on my behalf, such contracts or other assurances as may be requested or required by any bank or other institution or individual when carrying out the powers granted herein; and prepare, execute and file in my name joint or separate federal and state tax returns, declarations of estimated tax for any year or years and related forms on my behalf and make any other related elections related thereto deemed necessary by my agent, including but not limited to federal gift tax returns on my behalf; including the authority to General Durable Power of Attorney Page 2 of 8 disclaim any assets otherwise passing to me; and to prepare, execute and file any claims for refund or any tax. 7. Acquire, purchase, exchange, buy or sell options to buy or sell and convey real or personal property, tangible or intangible, or any interest therein, on such terms and conditions as my agent shall deem proper. Execute and deliver, in my name and on my behalf, conveyances of real or personal property including, but not limited to my homestead, for any consideration to my spouse, children and/or their issue, of any such real or personal property owned by me at any time, including the execution of promissory notes and deeds of trust and including instruments necessary to purchase real or personal property in my name, as well as the execution or release of such deeds of trust or other security agreements as may be necessary or proper in the exercise of the rights and powers herein granted; 8. HEALTH CARE : Execute in my name and on my behalf such medical insurance forms, including but not limited to Medicare and Medicaid claim forms, and other medical, hospitalization or health insurance forms as may be requested or required on my behalf, including admittance and release forms and authorizations for treatment of any kind; and to make any and all health care decisions for me if I be unable to give informed consent with respect to any given health care decision; and shall have all those powers and rights which are provided by Florida Law and to make any and all health care decisions for me, including, but not limited to those set forth in Chapter 765, Florida Statutes. 9. Operate any business or corporation on my behalf in the same capacity as I would have with the same powers and authority possessed by me at that time, including but not limited to exercising stock options and voting all of my shares of stock in said corporation or corporations without the necessity of a proxy and the right to appoint proxies therefore, and possessing all powers that I possess as granted to me by the Bylaws of said corporation or corporations, to incorporate, reorganize, merge, consolidate, recapitalize, sell, liquidate or dissolve any business; elect or employ officers, directors and agents; carry out the provisions of any agreement for the sale of any business interest or the stock therein; 10. Commence, prosecute, discontinue or defend all actions or other legal proceedings or remedies touching my affairs or estate or any part thereof as may be deemed necessary by my agent; and to adjust, sell, compromise, settle, and agree for the same, and to execute and deliver for me, on my behalf, and in my name, all endorsements, releases, receipts, or other sufficient discharges for the same; 11. Borrow any sum or sums of money on such terms and with security, whether real or personal property, as my agent may deem necessary, and to execute all promissory notes, deeds of trust and other instruments which may prove necessary or proper; to borrow against margin accounts on stock and other investments and pledge assets therefore; 12. Engage, employ and dismiss any agents, servants, advisors, including accountants, attorneys or other persons in and about the performance of these duties as my agent shall deem necessary and grant such persons discretionary power; General Durable Power of Attorney Page 3 of 8 13. Receive and receipt for any distribution from any trust under which I am the beneficiary and to withdraw on my behalf any funds or assets held in any trust operating for my benefit, by assignment, conveyance or otherwise; 14. Hold, purchase or invest in my name in "wasting assets" such as life estates or life interests in property and "unproductive assets" such as reminder interests in property if deemed advisable by my agent; 15. This instrument is to be construed and interpreted as a general durable power of attorney. The enumeration of specific powers herein is not intended to, nor does it, limit or restrict the general powers herein granted to my agent. This instrument is executed and delivered in the State of Florida, and the laws of the State of Florida shall govern all questions as to validity of this power and the construction of its provisions; 16. 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. 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) With respect to a trust created by or on behalf of the principal, amend, modify, revoke, or terminate the trust, but only if the trust instrument explicitly provides for amendment, modification, revocation, or termination by the settlor's agent; ______ (c) Make a gift, subject to subsection (4) of Florida Statutes 709.2202 ; ______ (d) Create or change rights of survivorship; ______ (e) Create or change a beneficiary designation; ______ (f) Waive the principal's right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan; or ______ (g) Disclaim property and powers of appointment. ______ (h) Authority to conduct investment transactions as provided in section 709.2208(2), Florida Statutes. ______ (i) Authority to conduct banking transactions as provided in section 709.2208(1), Florida Statutes. 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; General Durable Power of Attorney Page 4 of 8 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 or transfer assets to an existing trust created by the principal unless expressly authorized by the power of attorney; or 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 so exercisable and effective regardless of the fact that I may be mentally or physically incapacitated or incapable of understanding or unable to express myself or act in my own behalf at the time of any action on my behalf by said agent. Such incapacity, whether mental or physical, that I may exhibit shall not in any way interfere with the authority of my agent herein to act fully on my behalf according to the terms hereof. In other words, this Power of Attorney shall not be affected by the subsequent disability, incompetence or incapacity of the principal. And I do hereby undertake to ratify and confirm, all and singular, the acts heretofore performed and to be hereinafter 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 do all of the following: (1) Request, review and receive any information, verbal or written, regarding my physical or mental health including, but not limited to, medical and hospital records; (2) Execute on my behalf any releases or other documents that may be required in order to obtain this information; (3) Consent to the disclosure of this information; and (4) Consent to the donation of any of my 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 the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR 160 through 164. I authorize any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered health care provider, any insurance company, and the Medical Information Bureau, Inc. or other health care clearinghouse that has provided treatment or services to me, or that has paid for or is seeking payment from me for such services, 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, including all information relating to the diagnosis of HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol abuse. The authority given my agent shall supersede any other agreement that I may have made with my General Durable Power of Attorney Page 5 of 8 health care providers to restrict access to or disclosure of my individually identifiable health information. 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 (your agent) the power to make health care decisions for you. This power exists only as to those health care decisions to which you are unable to give informed consent. The attorney - in - fact must act consistently with your desires as stated in this document or otherwise made known. Except as you otherwise specify in this document, 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 in s. 709.2108, Florida Statutes. The attorney in fact must be a natural person who is 18 years or older and is of sound mind, or a financial institution, as defined in chapter 655, Florida Statutes, with trust powers, and having a place of business in the State of Florida and be authorized to conduct trust business in the State of Florida. A not - for - profit corporation, organized for charitable or religious purposes in this state, which has qualified as a court - appointed guardian prior to January 1, 1996, and which is a tax - exempt organization under 26 U.S.C. s. 501(c) (3), may also act as an attorney in fact. Notwithstanding any contrary clause in the written power of attorney, no assets of the principal may be used for the benefit of the corporate attorney in fact, or its officers or directors. 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 with respect to the particular decision. In addition, no treatment may be given to you over your objection, and health care necessary to keep you alive may not be stopped or withheld if you object at the time. The document gives your agents authority to consent, to refuse to consent or to withdraw consent to any care, treatment, service or procedure to maintain, diagnose or treat a physical or mental condition. This power is subject to any statement of your desires and any limitations that you include in this document. You may state in this document any types of treatment that you do not desire. In additions, a court can take away the power of your agents to make health care decisions for you if your agents (a) authorizes anything that is illegal, (b) acts contrary to your known desires, or (c) where your desires are not known, does anything that is clearly contrary to your best interests. You have the right to revoke the authority of your agents by notifying your agents or your treating doctor, hospital or other health care provider in writing of the revocation. General Durable Power of Attorney Page 6 of 8 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 in this document, this document gives your agents the power after you die to (a) authorize an autopsy, (b) donate your body or parts thereof for transplant or for educational, therapeutic or scientific purposes, and (c) direct the disposition of your remains. If there is anything in this document that you do not understand, you should ask your lawyer to explain it to you. IN WITNESS WHEREFORE, I have executed this General Durable Power of Attorney consisting of _________ pages this the _________ day of ____________ , 20       . Signature of Principal _________________________________________ Type/Print Name _________________________________________ City, County, State of Residence ATTESTATION The hereinafter named Witnesses, each declare under penalty of perjury under the laws of the State of Florida that the principal is personally known to us, that the principal signed and acknowledged this durable power of attorney in our presence, that the principal appears to be of sound mind and under no duress, fraud or undue influence, that we are not the person appointed as attorney - in - fact by this document, and that we are not a health care provider, nor an employee of a health care provider or facility. We are not related to the principal by blood, marriage or adoption, and to the best of our knowledge, are not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law. Witness our signatures, this the       day of ____________ , 20       . WITNESSES: __________________________________ of _________________________________________ (Signature) (Street Address) _________________________________________ _________________________________________ (Print or Type Name) (City, State, Zip Code) __________________________________ of _________________________________________ (Signature) (Street Address) _________________________________________ _________________________________________ (Print or Type Name) (City, State, Zip Code) General Durable Power of Attorney Page 7 of 8 State of Florida, County of _________________________________________ The foregoing instrument was acknowledged before me this ____________ , (Date) By _________________________________________ , (name of person(s) acknowledging) who is/are personally known to me or has produced ____________________________ (type of identification) as identification. Commission No. ____________________________ Notary Public My Commission expires: ____________ _________________________________________ Type or Print Name General Durable Power of Attorney Page 8 of 8