Fill and Sign the Ky Power Attorney Form

SPECIAL DURABLE POWER OF ATTORNEY FOR BANK ACCOUNT MATTERS STATE OF KENTUCKY COUNTY OF ________________________ KNOW ALL MEN BY THESE PRESENTS: That I, ____________________________________ of ________________________ County, Kentucky, being of sound mind and memory, do hereby make, constitute and appoint ____________________________________ 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 related to or connected with my bank accounts at ____________________________________ Bank, ____________________________________ (Address), ____________________________________ (City), Kentucky, ___________ (Zip Code) hereinafter “Bank”, including, but not limited to, the following: 1. Making deposits, transfers and withdrawals to or from any of my bank accounts at Bank. 2. Writing, making and endorsing checks, drafts and other instruments in connection with my bank accounts at Bank. 3. Opening new checking, savings, money market, certificates of deposit, IRA’s or other accounts in my name and maintaining same. 4. Approving and authorizing automatic withdrawals from my accounts. 5. Executing signature cards for accounts maintained or opened by my agent in my name. 6. Performing any and all other matters relating to, or in connection with, my bank accounts at Bank. This is a durable power of attorney and the authority of my attorney in fact shall not terminate if I become disabled or in the event of later uncertainty as to whether I am dead or alive. 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. Bank shall honor this Power of Attorney until and unless Bank receives written notice of revocation of same signed by me. Bank is hereby indemnified and shall be held harmless by the undersigned for any and all actions taken by my agent regarding my accounts at Bank, regardless of whether within the intended scope of this Power of Attorney or not; therefore, Bank shall have no liability for the actions of my agent or for following the directions of my agent in connection with my bank accounts at Bank. IN WITNESS WHEREFORE, I have executed this Special Power of Attorney on 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 Kentucky, that the principal is personally known to us, that the principal signed and acknowledged this special 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 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: WITNESSES: ______________________________ Signature Print Name: ___________________________ Address: ______________________________ City: ________________ State: ___________ Zip: __________ ______________________________ Signature Print Name: ___________________________ Address: ______________________________ City: ________________ State: ___________ Zip: __________ AGENT'S ACCEPTANCE OF AUTHORITY I, _______________________ (insert name of agent), accept appointment as agent under this power of attorney for _______________________ (insert name of principal). Dated: _______________________ ______________________________ (Agent's Signature) _______________________ (Print Agent's Name) State of Kentucky County of _______________________ This instrument was acknowledged before me on _______________________ by _______________________. _________________________________. (Signature of notarial officer) (Seal, if any) _________________________________ Title (and Rank) My appointment expires: _______ Principal Name and Address Name: Attorney-in-Fact Name and Address Name: Address: Address: City: City: State: Phone: Zip: State: Phone: Zip: