Fill and Sign the Power Attorney Form 481377003

STATUTORY GENERAL POWER OF ATTORNEY (Connecticut General Statutes 1-352) NOTICE: THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD AND SWEEPING. THEY ARE DEFINED IN CONNECTICUT STATUTORY SHORT FORM POWER OF ATTORNEY ACT, WHICH EXPRESSLY PERMITS THE USE OF ANY OTHER OR DIFFERENT FORM OF POWER OF ATTORNEY DESIRED BY THE PARTIES CONCERNED. THE GRANTOR OF ANY POWER OF ATTORNEY OR THE AGENT MAY MAKE APPLICATION TO A COURT OF PROBATE FOR AN ACCOUNTING AS PROVIDED IN SUBSECTION (B) OF SECTION 45A-175 OF THE GENERAL STATUTES. THIS POWER OF ATTORNEY DOES NOT AUTHORIZE THE AGENT TO MAKE HEALTH CARE DECISIONS FOR YOU. Know All Men by These Presents, which are intended to constitute a GEN ERAL POWER OF ATTORNEY pursuant to Connecticut Statutory Short Form Power of Attorney Act: That I _______________________________ ( insert name and address of the principal) do hereby appoint _______________________________ (insert name and address of the agent, or each agent, if more than one is designated) my agent(s) TO ACT ____________________________________. ( If more than one agent is designated and the principal wishes each agent alone to be able to exercise the power conferr ed, insert in this blank the word 'severally'. Failure to make any insertion or the insertion of the word 'jointly' shall require the agents to act jointly.) First: In my name, place and stead in any way which I myself c ould do, if I were personally present, with respect to the following matters as each of t hem is defined in the Connecticut Uniform Power of Attorney Act to the extent that I am permit ted by law to act through an agent: (Strike out and initial in the opposite box any one or more of the subdivisions as to which the principal does NOT desire to give the agent authority. Such elimination of any one or more of subdivisions (A) to (M), inclusive, shall autom atically constitute an elimination also of subdivision (N).) To strike out any subdivis ion the principal must draw a line through the text of that subdivision AND write his initials in the box opposite.) _____ (A) real estate transactions (real property); _____ (B) chattel and goods transactions (tangible personal property); _____ ( C) bond, share and commodity transactions (stocks and bonds); _____ (D) banking transactions (banks and other financial institutions); _____ (E) business operating transactions (operations of entity or business); _____ (F) insurance transactions (insurance and annuities); _____ (G) estate transactions (estates, trusts, and other beneficial interests); _____ (H) claims and litigation; _____ (I) personal relationships and affairs (personal and family maintenance); _____ (J) benefits from military service (benefits from governmental programs or civil or military service); _____ (K) records, reports and statements; _____ (L) retirement plans; _____ (M) taxes: _____ (N) all other matters; (Special provisions and limitations may be included in the statutory form power of attorney only if they conform to the requirements of the Connecticut Unif orm Power of Attorney Act.) (Strike out below and initial in the opposite box any one or more of the s ubdivisions as to which the principal does NOT desire to give the agent authority. To strike out any subdivision the principal must draw a line through the text of that subdivision AND write his/her initials in the box opposite.) (CAUTION: Granting any of the following will give your agent the authority to take actions that could significantly reduce your property or change how your property is distributed at your death.) YOU SHOULD SEEK LEGAL ADVICE BEFORE INCLUDING THE FOLLOWING POWERS: _____ (O) Create, , amend, revoke or terminate an inter vivos trust, provided in the case of a trust established for a disabled person pursuant to 42 USC 1396p (d )(4)(A) or 42 USC 1396p (d)(4)(C), the creation of such trust by an agent shall be only as permitted by federal law; _____ (P) Make a gift, subject to the limitations of the Connecticut Uniform Power of Attorney Act and any special instructions in this power of attorney. Unless otherwise provided in the special instructions, gifts per recipient may not exceed the annual dollar limits of the federal gift tax exclusion under Internal Revenue Code Section 2503(b), or if the principal’s spouse agrees to consent to a split gift pursuant to I nternal Revenue Code Section 2513, in an amount per recipient not to exceed twice the annual federal gift tax exclusion limit. In addition, an agent must determine that gift s are consistent with the principal’s objectives if actually known by the agent and, if unknown, as the agent determines is consistent with the principal’s best int erest based on all relevant factors; _____ (Q) Create or change rights of survivorship; _____ (R) Create or change a beneficiary designation; _____ (S) Authorize another person to exercise the authority granted under this power of attorney; _____ (T) Waive the principal’s right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan; _____ (U) Exercise fiduciary powers that the principal has authority to delegate; _____ (V) Disclaim or refuse an interest in property, including a power of appointment. Second: With full and unqualified authority to delegate any or all of the foregoing powers to any person or persons whom my agent(s) shall select; Third: Hereby ratifying and confirming all that said agent(s) or substitute(s) do or cause to be done. Fourth: LIMITATION ON AGENT’S AUTHORITY An agent that is not my ancestor, spouse, or descendant MAY NOT use 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. Fifth: DESIGNATION OF SUCCESSOR AGENT(S) (OPTIONAL) If my agent is unable or unwilling to act for me, I name as my successor agent: Name of Successor Agent: _______________________________ Successor Agent’s Address: _______________________________ If my successor agent is unable or unwilling to act for me, I name as my second successor agent: Name of Second Successor Agent: _______________________________ Second Successor Agent’s Address: _______________________________ Sixth: EFFECTIVE DATE This power of attorney is effective immediately unless I have stated otherwise in the special instructions. In Witness Whereof I have hereunto signed my name and affixed my seal this day of _________________, 20 . ____________________________________ Signature of Principal (Seal) State of Connecticut County of ________________________ (Town/City) On seal this day of _________________, 20 , before me, ______________ (Name of Notary), the undersigned officer, personally appeared ________________________________ (Name of individual or individuals), known to me (or satisfactorily proven) to be the person(s) whose name(s) (is or are) subscri bed to the within instrument and acknowledged that (he, she or they) executed the sam e for the purposes therein contained. In witness whereof I hereunto set my hand. Date: ___________________________________ Signature of Notary Public My Commission Expires: