New York Statutory Short Form Power of Attorney

DURABLE GENERAL POWER OF ATTORNEY EFFECTIVE
AT A FUTURE TIME NEW YORK STATUTORY SHORT FORM

(New York State Consolidated Laws, General Obligations, S 5-1506)

THE POWERS YOU GRANT BELOW CONTINUE TO BE EFFECTIVE
SHOULD YOU BECOME DISABLED OR INCOMPETENT

(CAUTION: THIS IS AN IMPORTANT DOCUMENT. IT GIVES THE PERSON WHOM YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY DURING YOUR LIFETIME, WHICH MAY INCLUDE POWERS TO MORTGAGE, SELL, OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THESE POWERS WILL CONTINUE TO EXIST EVEN AFTER YOU BECOME DISABLED OR INCOMPETENT. THESE POWERS ARE EXPLAINED MORE FULLY IN NEW YORK GENERAL OBLIGATIONS LAW, ARTICLE 5, TITLE 15, SECTIONS 5-1502A THROUGH 5-1503, WHICH EXPRESSLY PERMIT THE USE OF ANY OTHER OR DIFFERENT FORM OF POWER OF ATTORNEY.

THIS DOCUMENT DOES NOT AUTHORIZE ANYONE TO MAKE MEDICAL OR OTHER HEALTH CARE DECISIONS. YOU MAY EXECUTE A HEALTH CARE PROXY TO DO THIS. IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.)

THIS is intended to constitute a DURABLE GENERAL POWER OF ATTORNEY pursuant to Article 5, Title 15 of the New York General Obligations Law:

I,

do hereby appoint:

my attorney(s)-in-fact TO ACT

(If more than one agent is designated, CHOOSE ONE of the following two choices by putting your initials in ONE of the blank spaces ( ) to the left of your choice:)

( ) Each agent may SEPARATELY act.

( ) All agents must act TOGETHER.

(If neither blank space is initialed, the agents will be required to act TOGETHER)

TO TAKE EFFECT upon the occasion of the signing of a written statement EITHER:

(INSTRUCTIONS: COMPLETE OR OMIT SECTION (I) --OR-- SECTION (II) BELOW BUT_NEVER COMPLETE BOTH SECTIONS (I) AND (II) BELOW. IF YOU DO NOT COMPLETE EITHER SECTION (I) OR SECTION (II) BELOW, IT SHALL BE PRESUMED THAT YOU WANT THE PROVISIONS OF SECTION (I) BELOW TO APPLY)

(I) by a physician or physicians named herein by me at this point:

Dr.

or if no physician or physicians are named hereinabove, or if the physician or physicians named hereinabove are unable to act, by my regular physician, or by a physician who has treated me within one year preceding the date of such signing, or by a licensed psychologist or psychiatrist, certifying that I am suffering from diminished capacity that would preclude me from conducting my affairs in a competent manner;

--OR--

(II) by a person or persons named herein by me at this point:

by You)

CERTIFYING that the following specified event has occurred:

IN MY NAME, PLACE AND STEAD in any way which I myself could do, if I were personally present, with respect to the following matters as each of them is defined in Title 15 of Article 5 of the New York General Obligations Law to the extent that I am permitted by law to act through an agent:

(DIRECTIONS: Initial in the blank space to the left of your choice any one or more of the following lettered subdivisions as to which you WANT to give your agent authority. If the blank space to the left of any particular lettered subdivision is NOT initialed, NO AUTHORITY WILL BE GRANTED for matters that are included in that subdivision. ALTERNATIVELY, the letter corresponding to each power you wish to grant may be written or typed on the blank line in subdivision "(Q)", and you may then put your initials in the blank space to the left of subdivision "(Q)" in order to grant each of the powers so indicated)

( ) (A) real estate transactions;

( ) (B) chattel and goods transactions;

( ) (C) bond, share and commodity transactions;

( ) (D) banking transactions;

( ) (E) business operating transactions;

( ) (F) insurance transactions;

( ) (G) estate transactions;

( ) (H) claims and litigation;

( ) (I) personal relationships and affairs;

( ) (J) benefits from military service;

( ) (K) records, reports and statements;

( ) (L) retirement benefit transactions;

( ) (M) making gifts to my spouse, children and more remote descendants, and parents, not to exceed in the aggregate $10,000 to each of such persons in any year;

( ) (N) tax matters;

( ) (O) all other matters;

( ) (P) full and unqualified authority to my attorney(s)-in-fact to delegate any or all of the foregoing powers to any person or persons whom my attorney(s)-in-fact shall select;

( ) (Q) each of the above matters identified by the following letters:

(Special provisions and limitations may be included in the statutory short form durable power of attorney only if they conform to the requirements of section 5-1503 of the New York General Obligations Law.)

This durable Power of Attorney shall not be affected by my subsequent disability or incompetence.

If every agent named above is unable or unwilling to serve, I appoint

to be my agent for all purposes hereunder.

TO INDUCE ANY THIRD PARTY TO ACT HEREUNDER, I HEREBY AGREE THAT ANY THIRD PARTY RECEIVING A DULY EXECUTED COPY OR FACSIMILE OF THIS INSTRUMENT MAY ACT HEREUNDER, AND THAT REVOCATION OR TERMINATION HEREOF SHALL BE INEFFECTIVE AS TO SUCH THIRD PARTY UNLESS AND UNTIL ACTUAL NOTICE OR KNOWLEDGE OF SUCH REVOCATION OR TERMINATION SHALL HAVE BEEN RECEIVED BY SUCH THIRD PARTY, AND I FOR MYSELF AND FOR MY HEIRS, EXECUTORS, LEGAL REPRESENTATIVES AND ASSIGNS, HEREBY AGREE TO INDEMNIFY AND HOLD HARMLESS ANY SUCH THIRD PARTY FROM AND AGAINST ANY AND ALL CLAIMS THAT MAY ARISE AGAINST SUCH THIRD PARTY BY REASON OF SUCH THIRD PARTY HAVING RELIED ON THE PROVISIONS OF THIS INSTRUMENT. THIS GENERAL POWER OF ATTORNEY EFFECTIVE AT A FUTURE TIME MAY BE REVOKED BY ME AT ANY TIME.

In Witness Whereof I have hereunto signed my name this day of , 20

(Signature of Principal)

ACKNOWLEDGEMENT

State of New York

County of

On the day of in the year before me, the undersigned, personally appeared

(Signature and office of individual taking acknowledgement.)

SPECIAL NOTES:

1. The execution of this statutory short form power of attorney effective at a future time shall be duly acknowledged by the principal in the manner prescribed for the acknowledgement of a conveyance of real property.

2. No provision of this article shall be construed to bar the use of any other or different form of power of attorney desired by the parties concerned.

3. Every statutory short form power of attorney effective at a future time, to be valid, must be written, typed or printed using letters which are in legible writing of or clear type of no less than twelve-point in size or if in writing a reasonable equivalent thereof and must contain, in bold face upper case or upper and lower case type or a reasonable equivalent thereof the "CAUTION" which is printed in bold face type at the beginning of the statutory form printed above and the "DIRECTIONS" which are printed in bold face type immediately before subdivisions (A) through (Q) of the statutory form printed above.