Fill and Sign the Know All Men by These Presents that I as Principal Do Hereby Make Constitute and Appoint Form

When Recorded mail to:__________________________________________________________________________________________________________________________________________________________________________________________ SPECIAL POWER OF ATTORNEY __________________________________________________________________________________________Principal___________________________________ Attorney-In-Fact ____________________________Address___________________________________ Address_____________________________________________________________________________ _________________________________________City/County/State/Zip City/County/State/ZipKNOW ALL MEN BY THESE PRESENTS, that I, as Principal, do hereby make, constitute, and appoint ______________________________________ as my true and lawful Attorney-In-Fact and to do the following:__________________________________________________________________________________________ __________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________ I.To exercise or perform any act, power, duty, right, or obligation whatsoever that I now have, or may hereafter acquire the legal right, power, or capacity to exercise or perform, in connection with, arising from, or relating to any act or instrument stated above. The Attorney-In-Fact shall use the my money, property, or other assets only in the my best interest and that the Attorney-In-Fact shall not use my money, property, or other assets for his/her benefit except as specifically described in detail and initialed by myself and Witnesses in numbers 3 and 4 below. Failure to comply with this provision could subject the Attorney-In-Fact to criminal charges or civil liability.1.The rights, powers, and authority of said Attorney-In-Fact herein granted shall commence and be in full force and effect on the date of execution of this document, and such rights, powers, and authority shall remain in full force and effect thereafter until __________________ or terminated prior to such date by written notice signed by me or by the appointment of a conservator for me by a Court Order.2.As Principal, I authorize my Attorney-In-Fact to receive the following reimbursement for reasonable amounts, travel costs, lodging, meals, attorney or accountant fees and the like: ________________________ ____________________________________________________________________________________________________________________________________________________________________________________Initial:Principal ______________ Witness _____________ Witness _______________3. My Attorney-In-Fact receives gifting from the following programs through my qualification of those programs. I, as Principal of this Power of Attorney authorize annual exclusion gifting from these programs to the Attorney-In-Fact as an entitlement rather than as a reimbursement arising from this Power of Attorney. ____________________________________________________________________________________ ____________________________________________________________________________________Initial:Principal ______________ Witness _____________ Witness _______________I, __________________________________, the principal, sign my name to this power of attorney this _____ day of __________________________________ and, being first duly sworn, do declare to the undersigned authority that I sign and execute this instrument as my power of attorney and that I sign it willingly, or willingly direct another to sign for me, that I execute it as my free and voluntary act for the purposes expressed in the power of attorney and that I am eighteen years of age or older, of sound mind and under no constraint or undue influence.________________________________________ Principal OATH AND VERIFICATION On this date:________________________________, before us, the undersigned Witness 1 and Witness 2, personally appeared the above Principal, respectively, known to us or satisfactorily proven to be the person whose name is subscribed to this instrument. We as Witnesses to this Power of Attorney declare that neither Witness 1 or Witness 2 is the above appointed Attorney-In-Fact, or the child or spouse of the Attorney-In-Fact or is the Notary Public signed below. The Principal, being duly sworn, did hereby declare that Principal signed and executed this instrument as Principal's Power of Attorney appointing the above named Attorney-In-Fact and had signed willingly and executed it as Principal's free and voluntary act for the purposes therein expressed, and that each of the Witnesses, in the presence of the Principal, Notary and each other signed this Power of Attorney as Witnesses; and that to the best of our knowledge, the Principal was at the time an adult, of sound mind and under no constraint or undue influence. This instrument was subscribed, sworn and acknowledged before us._____________________________________________ ______________________________________Witness 1Witness 2___________________________________________________________________________________AddressAddress___________________________________________________________________________________PrincipalAttorney-In-FactOn this _____ of __________________________________, 20___, personally appeared before me, _______________________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the above named Principal whose name is subscribed to this instrument, and acknowledged that he/she executed the same in front of myself and the above signed Witnesses. At the time of execution the Principal was at the time an adult, of sound mind and under no constraint or undue influence. Notary Public____________________________________________ (seal)