Power of Attorney Request Form

Power of Attorney Request Form

This Power of Attorney Request Form is executed on by and between Principal Name: and Agent (Attorney‑in‑Fact) Name: (each a "Party" and collectively the "Parties").

Recitals

WHEREAS, Principal is of sound mind and seeks to appoint an agent to act on Principal's behalf in accordance with the terms set forth herein; and

WHEREAS, Agent has agreed to accept appointment and to serve in a fiduciary capacity subject to the duties, limitations, and authorities contained in this instrument; and

WHEREAS, Principal requests preparation and execution of a limited or general power of attorney document based upon the selections and instructions provided in this Request Form.

Now, Therefore

NOW THEREFORE, in consideration of the mutual covenants contained herein and intending to be legally bound, the Parties agree as follows:

1. Appointment and Scope

1.1 Appointment. Principal hereby requests that Agent be appointed as Principal's attorney‑in‑fact with the authority to act for Principal with respect to the matters specified in this Request Form and any power of attorney document created pursuant to this Request Form.

1.2 Scope of Authority. Select the requested scope of authority to be granted to Agent:

General authority to manage all legal and financial affairs of Principal, including but not limited to banking, real property, tax matters, business interests, insurance, retirement accounts, and claims and litigation handling.
Specific authority limited to the powers described below (if selected, complete the description field):

2. Effective Date; Duration; Termination

2.1 Effective Date. The requested power of attorney shall become effective on unless specified otherwise in the executed power of attorney instrument.

2.2 Duration and Termination. Unless earlier revoked in writing by Principal or terminated by operation of law, the power of attorney shall remain in effect until or until otherwise stated in the executed instrument.

3. Duties, Standards and Limitations

3.1 Fiduciary Duty. Agent shall exercise all powers granted under this Request Form and any resulting power of attorney in good faith, in the Principal's best interests, and with the care an ordinarily prudent person in a like position would exercise under similar circumstances.

3.2 Limitations. The following limitations apply to Agent's authority:

4. Compensation and Expenses

4.1 Compensation. Agent shall be entitled to compensation as follows:

4.2 Expenses. Agent shall be reimbursed for reasonable expenses incurred while performing duties hereunder, subject to Principal's accounting and records requests.

5. Reliance by Third Parties

5.1 Third‑party Reliance. Third parties who receive a copy of any power of attorney executed pursuant to this Request Form may rely upon the representations of Agent as to the existence of the authority granted and shall be protected from liability for actions taken in good faith reliance on the power of attorney.

5.2 Indemnity. Principal agrees to indemnify and hold harmless any third party who acts in reliance upon a power of attorney executed pursuant to this Request Form, except for actions resulting from the third party's intentional misconduct or gross negligence.

6. Revocation

6.1 Revocation Procedure. Principal may revoke any power of attorney executed pursuant to this Request Form by delivering a written revocation to Agent and to any third parties reasonably expected to rely upon the power of attorney. Address for delivery of revocation to Agent:

7. Notices

All notices and communications required or permitted under this Request Form shall be in writing and delivered to the addresses below by hand, certified mail, or other delivery service providing proof of delivery.

8. Acceptance by Agent

Agent hereby acknowledges receipt of the foregoing appointment request and agrees to act in the capacity of attorney‑in‑fact if a power of attorney is executed in the terms requested. Agent understands the fiduciary duties and potential liabilities associated with the role.

9. Miscellaneous Provisions

9.1 Governing Law. This Request Form and any power of attorney executed pursuant to it shall be governed by and construed in accordance with the laws of the State of , without regard to conflict of laws principles.

9.2 Entire Agreement. This Request Form constitutes the entire understanding between the Parties with respect to the subject matter hereof and supersedes all prior negotiations and agreements, whether written or oral, relating to the same subject matter.

9.3 Amendments; Waiver. Any amendment or waiver of any provision of this Request Form must be in writing and signed by both Parties. No waiver of any breach shall constitute a waiver of any subsequent breach.

9.4 Severability. If any provision of this Request Form is determined to be invalid or unenforceable under applicable law, such provision shall be severed and the remaining provisions shall remain in full force and effect.

9.5 Counterparts. This Request Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

Certification

Principal certifies that the information provided in this Request Form is true and complete to the best of Principal's knowledge, that Principal has the capacity and legal right to execute a power of attorney, and that Principal understands the nature and effect of granting the requested authorities. Principal understands that separate notarization or witness signatures may be required to affect the power granted under law.

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