Fill and Sign the Illinois Limited Power of Attorney for Stock Transactions and Corporate Powers Form

- 1 - LIMITED POWER OF ATTORNEY FOR STOCK TRANSACTIONS AND OTHER CORPORATE POWERS STATE OF ILLINOIS COUNTY OF ____________ KNOW ALL MEN BY THESE PRESENT, THAT I __________________________________, whose address is ___________________________________, __________________________ (City), Illinois, __________ (Zip), 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: Exercising stock options and voting all of my shares of stock in _______________________ ___________________________, a Corporation incorporated in the State of ____________________________, hereinafter "Corporation", without the necessity of a proxy and the right to appoint proxies therefor, and possessing all powers that I posses s as granted to me by the Bylaws of said corporation, 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 there in. These powers include, but are not limited to, the following: A. Receive, hold, transfer, sell and convey any stock certificate s of the Corporation and all documents of title in connection therewith; B. Make, execute and deliver, in my name and on my behalf, for any considera tion whatsoever, for cash, instruments of conveyance covering the stock of the Corpora tion, containing such terms, covenants and conditions deemed necessary or advisable by my agent; C. 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 D. Acquire, exchange, buy or sell my stock in the corporation, or any interest therein, on such terms and conditions as my agent shall deem proper. Execute and deliv er, in my name and on my behalf, conveyances of said stock. FURTHER, I do authorize my aforesaid attorney to execute, acknowledge and de liver any instrument under seal or otherwise, and to do all things necessary to carry out the intent here of, hereby granting unto my said attorney full power and authority to act in and concerning the premi ses as fully and effectually as I may do if personally present, limited, however, to the purpose for which this limit ed 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 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". - 2 - This Power of Attorney shall be: ( ) Non-Durable ( ) Durable and shall not be affected by any subsequent disability or incompetence. I further declare that any act or thing lawfully done hereunder and within t he powers herein stated by my said attorney shall be binding on myself and my heirs, legal and pe rsonal representatives and assigns, whether the same shall have been done either before or after my death, or other revocation of this i nstrument, unless and until reliable intelligence or notice thereof shall have been received by my said attorney. 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 representat ions 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____. ______________________________________________ PRINCIPAL ______________________________ WITNESS ______________________________ WITNESS ATTESTATION The hereinafter named Witnesses, each declare under penalty of perjury under the laws of the State of Illinois, that the principal is personally known to us, that the principal si gned and acknowledged this Limited power of attorney in our presence, that the principal appears to be of sound mind and under no dures s, fraud or undue influence, that we are not the person appointed as attorney- in-fact by this document and that we witnessed this power of attorney in the presence of the principal. 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. WITNESSES: ______________________________ Signature Print Name: ___________________________ Address: ______________________________ City: ________________ State: ___________ Zip: __________ WITNESSES: ______________________________ Signature Print Name: ___________________________ Address: ______________________________ City: ________________ State: ___________ Zip: __________ - 3 - Principal Name and Address Attorney-in-Fact Name and Address Name: Name: Address: Address: City: City: State: Zip: State: Zip: Phone: Phone: NOTICE TO AGENT When you accept the authority granted under this power of attorney a special legal relationship, know n as agency, is created between you and the principal. Agency imposes upon you duties that continue until you resign or the power of attorney is terminated or revoked. As agent you must: (1) do what you know the principal reasonably expects you to do with the principal's property; (2) act in good faith for the best interest of the principal, using due care, competence, and diligenc e; (3) keep a complete and detailed record of all receipts, disbursements, and significant acti ons conducted for the principal; (4) attempt to preserve the principal's estate plan, to the extent actually known by the agent , if preserving the plan is consistent with the principal's best interest; and (5) cooperate with a person who has authority to make health care decisions for the principal to carry out the principal's reasonable expectations to the extent actually in the principal's best inte rest. As agent you must not do any of the following: (1) act so as to create a conflict of interest that is inconsistent with the other principl es in this Notice to Agent; (2) do any act beyond the authority granted in this power of attorney; (3) commingle the principal's funds with your funds; (4) borrow funds or other property from the principal, unless otherwise authorized; (5) continue acting on behalf of the principal if you learn of any event that terminates this powe r of attorney or your authority under this power of attorney, such as the death of the principal, your legal separation from the principal, or the dissolution of your marriage to the principal. If you have special skills or expertise, you must use those special skills and expertise when acting for the principal. You must disclose your identity as an agent whenever you act for the principal by writi ng or printing the name of the principal and signing your own name "as Agent" in the following manner: "(Principal's Name) by (Your Name) as Agent" The meaning of the powers granted to you is contained in Section 3 ‑4 of the Illinois Power of Attorney Act, which is incorporated by reference into the body of the power of attorney for property document. - 4 - If you violate your duties as agent or act outside the authority granted to you, you may be liable for any damages, including attorney's fees and costs, caused by your violation. If there is anything about this document or your duties that you do not understand, you should seek legal advice from an attorney.