Fill and Sign the Ohio Statutory Form Power of Attorney Ohio State Bar

OHIO STATUTORY FORM POWER OF ATTORNEY IMPORTANT INFORMATION This power of attorney authorizes another person (your agent) to m ake decisions concerning your property for you (the principal). Your agent will be able to make decisions and act with respect to your property (including your money) whether or not you are able to act for yourself. The meaning of authority o ver subjects listed on this form is explained in the Uniform Power of Attorney Act (sections 13 37.21 to 1337.64 of the Revised Code). This power of attorney does not authorize the agent to make health-c are decisions for you. You should select someone you trust to serve as your agent. Unless you specify otherwise, generally the agent’s authority will continue until you die or revoke the power of attorney or the agent resigns or is unable to act for you. Your agent is entitled to reasonable compensation unless you state o therwise in the Special Instructions. This form provides for designation of one agent. If you wish to na me more than one agent you may name a co-agent in the Special Instructions. Co-age nts are not required to act together unless you include that requirement in the Special Ins tructions. If your agent is unable or unwilling to act for you, your power o f attorney will end unless you have named a successor agent. You may also name a se cond successor agent. This power of attorney becomes effective immediately unless you sta te otherwise in the Special Instructions. ACTIONS REQUIRING EXPRESS AUTHORITY Unless expressly authorized and initialed by me in the Special Instruc tions, this power of attorney does not grant authority to my agent to do any of the fo llowing: (1) Create a trust; (2) Amend, revoke, or terminate an inter vivos trust, even if s pecific authority to do so is granted to the agent in the trust agreement; (3) Make a gift; (4) Create or change rights of survivorship; (5) Create or change a beneficiary designation; (6) Delegate authority granted under the power of attorney; (7) Waive the principal’s right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan; (8) Exercise fiduciary powers that the principal has authority to delegate. CAUTION: Granting any of the above eight powers will give your agent the auth ority to take actions that could significantly reduce your property or change how your property is distributed at your death. If you have questions about the power of attorney or the author ity you are granting to your agent, you should seek legal advice before signing this form. DESIGNATION OF AGENT I, ______________________________ (Name of Principal) name the following person as my agent: Name of Agent: ______________________________ Agent’s Address: ______________________________ Agent’s Telephone Number: ______________________________ DESIGNATION OF SUCCESSOR AGENT (OPTIONAL) If my agent is unable or unwilling to act for me, I name as my s uccessor agent: Name of Successor Agent: _____________________________ _ Successor Agent’s Address: ____________________________ __ Successor Agent’s Telephone Number: _____________________ _________ If my successor agent is unable or unwilling to act for me, I n ame as my second successor agent: Name of Second Successor Agent: ______________________ ________ Second Successor Agent’s Address: ______________________ ________ Second Successor Agent’s Telephone Number: _______________ _______________ GRANT OF GENERAL AUTHORITY I grant my agent and any successor agent general authority to ac t for me with respect to the following subjects as defined in the Uniform Power of Attorney Act (sections 1337.21 to 1337.64 of the Revised Code): (INITIAL each subject you want to include in the agent’s general authority. If you wish to grant general authority over all of the subjects you may initial “All Pr eceding Subjects” instead of initialing each subject.) (_____) Real Property (_____) Tangible Personal Property (_____) Stocks and Bonds (_____) Commodities and Options (_____) Banks and Other Financial Institutions (_____) Operation of Entity or Business (_____) Insurance and Annuities (_____) Estates, Trusts, and Other Beneficial Interests (_____) Claims and Litigation (_____) Personal and Family Maintenance (_____) Benefits from Governmental Programs or Civil or Military Ser vice (_____) Retirement Plans (_____) Taxes (_____) All Preceding Subjects LIMITATION ON AGENT’S AUTHORITY An agent that is not my ancestor, spouse, or descendant MAY NOT u se my property to benefit the agent or a person to whom the agent owes an obligation of support unless I have included that authority in the Special Instructions. SPECIAL INSTRUCTIONS (OPTIONAL) You may give special instructions on the following lines: ___________________________________________________ ___________ ___________________________________________________ ___________ ___________________________________________________ ___________ EFFECTIVE DATE This power of attorney is effective immediately unless I have stated otherwise in the Special Instructions. NOMINATION OF GUARDIAN (OPTIONAL) If it becomes necessary for a court to appoint a guardian of my estate or my person, I nominate the following person(s) for appointment: Name of Nominee for guardian of my estate: _______________ _________________ Nominee’s Address: ________________________________ Nominee’s Telephone Number: ______________________________ __ Name of Nominee for guardian of my person: ______________ __________________ Nominee’s Address: ________________________________ Nominee’s Telephone Number: ______________________________ __ RELIANCE ON THIS POWER OF ATTORNEY Any person, including my agent, may rely upon the validity of this po wer of attorney or a copy of it unless that person knows it has terminated or is invalid. SIGNATURE AND ACKNOWLEDGMENT __________________________ _____________________ Your Signature Date Your Name Printed: ________________________________ Your Address: ________________________________ Your Telephone Number: ________________________________ State of Ohio County of ________________________________ This document was acknowledged before me on _________________ (Date), by ________________________________ (Name of Principal). __________________________________ Signature of Notary My commission expires: __________________ This document prepared by: ________________________________IMPORTANT INFORMATION FOR AGENT Agent’s Duties When you accept the authority granted under this power of attorney, a special legal relationship is created between you and the principal. This relationship impo ses upon you legal duties that continue until you resign or the power of attorney is terminated or revoked. You must: (1) Do what you know the principal reasonably expects you to do with th e principal’s property or, if you do not know the principal’s expectations, act in the principal’s best interest; (2) Act in good faith; (3) Do nothing beyond the authority granted in this power of attorney; (4) Attempt to preserve the principal’s estate plan if you know the plan a nd preserving the plan is consistent with the principal’s best interest; (5) Disclose your identity as an agent whenever you act for the pr incipal by writing or printing the name of the principal and signing your own name as “agent” in the following manner: (Principal’s Name) by (Your Signature) as Agent Unless the Special Instructions in this power of attorney state other wise, you must also: (1) Act loyally for the principal’s benefit; (2) Avoid conflicts that would impair your ability to act in the principal’s best interest; (3) Act with care, competence, and diligence; (4) Keep a record of all receipts, disbursements, and transactions made on behalf of the principal; (5) Cooperate with any person that has authority to make health-care decisions for the principal to do what you know the principal reasonably expects or, if yo u do not know the principal’s expectations, to act in the principal’s best interest. Termination of Agent’s Authority You must stop acting on behalf of the principal if you learn of an y event that terminates this power of attorney or your authority under this power of attorn ey. Events that terminate a power of attorney or your authority to act under a po wer of attorney include: (1) The death of the principal; (2) The principal’s revocation of the power of attorney or your authority; (3) The occurrence of a termination event stated in the power of a ttorney; (4) The purpose of the power of attorney is fully accomplished; (5) If you are married to the principal, a legal action is filed with a co urt to end your marriage, or for your legal separation, unless the Special Instru ctions in this power of attorney state that such an action will not terminate your authority. Liability of Agent The meaning of the authority granted to you is defined in the Unifor m Power of Attorney Act (sections 1337.21 to 1337.64 of the Revised Code). If you v iolate the Uniform Power of Attorney Act or act outside the authority granted, you may be liable for any damages caused by your violation. If there is anything about this document or your duties that you do not understand, you should seek legal advice.