Fill and Sign the Special Durable Power of Attorney for Bank Account Matters Form

SPECIAL DURABLE POWER OF ATTORNEY FOR BANK ACCOUNT MATTERS CAUTION TO THE PRINCIPAL: YOUR POWER OF ATTORNEY IS AN IMPORTANT DOCUMENT. AS THE "PRINCIPAL," YOU GIVE THE PERSON WHOM YOU CHOOSE (YOUR "AGENT") AUTHORITY TO SPEND YOUR MONEY AND SELL OR DISPOSE OF YOUR PROPERTY DURING YOUR LIFETIME WITHOUT TELLING YOU. YOU DO NOT LOSE YOUR AUTHORITY TO ACT EVEN THOUGH YOU HAVE GIVEN YOUR AGENT SIMILAR AUTHORITY. WHEN YOUR AGENT EXERCISES THIS AUTHORITY, HE OR SHE MUST ACT ACCORDING TO ANY INSTRUCTIONS YOU HAVE PROVIDED OR, WHERE THERE ARE NO SPECIFIC INSTRUCTIONS, IN YOUR BEST INTEREST. "IMPORTANT INFORMATION FOR THE AGENT” AT THE END OF THIS DOCUMENT DESCRIBES YOUR AGENT'S RESPONSIBILITIES. YOUR AGENT CAN ACT ON YOUR BEHALF ONLY AFTER SIGNING THE POWER OF ATTORNEY BEFORE A NOTARY PUBLIC. YOU CAN REQUEST INFORMATION FROM YOUR AGENT AT ANY TIME. IF YOU ARE REVOKING A PRIOR POWER OF ATTORNEY BY EXECUTING THIS POWER OF ATTORNEY, YOU SHOULD PROVIDE WRITTEN NOTICE OF THE REVOCATION TO YOUR PRIOR AGENT(S) AND TO THE FINANCIAL INSTITUTIONS WHERE YOUR ACCOUNTS ARE LOCATED. YOU CAN REVOKE OR TERMINATE YOUR POWER OF ATTORNEY AT ANY TIME FOR ANY REASON AS LONG AS YOU ARE OF SOUND MIND. IF YOU ARE NO LONGER OF SOUND MIND, A COURT CAN REMOVE AN AGENT FOR ACTING IMPROPERLY. YOUR AGENT CANNOT MAKE HEALTH CARE DECISIONS FOR YOU. YOU MAY EXECUTE A "HEALTH CARE PROXY" TO DO THIS. THE LAW GOVERNING POWERS OF ATTORNEY IS CONTAINED IN THE NEW YORK GENERAL OBLIGATIONS LAW, ARTICLE 5, TITLE 15. THIS LAW IS AVAILABLE AT A LAW LIBRARY, OR ONLINE THROUGH THE NEW YORK STATE SENATE OR ASSEMBLY WEBSITES, WWW.SENATE.STATE.NY.US OR WWW.ASSEMBLY.STATE.NY.US. IF THERE IS ANYTHING ABOUT THIS DOCUMENT THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. STATE OF NEW YORK COUNTY OF _______________________ KNOW ALL MEN BY THESE PRESENTS:That I, _______________________, of _______________________ County, New York, 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, indivi dually, 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), New York, _______________________ (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. 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 physica lly incapacitated or incapable of understanding or unable to express myself or act in my own behalf at the ti me of any action on my behalf by said agent. Such incapacity, whether mental or physical, tha t 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 m y 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, regardle ss 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. SIGNATURE AND ACKNOWLEDGMENT: In Witness Whereof I have hereunto signed my name on ____________________________________, 20     . PRINCIPAL signs here: ► __________________________________________ Individual Capacity within the State of New York State of New York, County of __________________, ss On the ______ day of __________________ in the year ____________ before me, the undersigned, personally appeared ________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity, and that by his signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Signature and Office of Person Taking Acknowledgement Type/Print Name: __________________________ Individual Capacity Outside the State of New York State of __________________, County of __________________, ss On the ______ day of __________________ in the year ____________ before me, the undersigned, personally appeared ______________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity, and that by his signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument and that such individual made such appearance before the undersigned in the ________________________ (insert the city or other political subdivision and the State or country or other place the acknowledgment was taken). Signature and Office of Person Taking Acknowledgement Type/Print Name: __________________________ IMPORTANT INFORMATION FOR THE AGENT:When you accept the authority granted under this Power of Attorney, a special legal relationship is created between you and the principal. This relationship imposes on you legal responsibilities that continue until you resign or the Power of Attorney is terminated or revoked. You must: (1) act according to any instructions from the principal, or, where there are no instructions, in the principal's best interest; (2) avoid conflicts that would impair your ability to act in the principal's best interest; (3) keep the principal's property separate and distinct from any assets you own or control, unless otherwise permitted by law; (4) keep a record or all receipts, payments, and transactions conducted for the principal; and (5) disclose your identity as an agent whenever you act for the principal by writing or printing the principal's name and signing your own name as "agent" in either of the following manners: (Principal's Name) by (Your Signature) as Agent, or (your signature) as Agent for (Principal's Name). You may not use the principal's assets to benefit yourself or anyone else or give gifts to yourself or anyone else unless the principal has specifically granted you that authority in this document, which is either a statutory gifts rider attached to a statutory short form power of attorney or a non-statutory power of attorney. If you have that authority, you must act according to any instructions of the principal or, where there are no such instructions, in the principal's best interest. You may resign by giving written notice to the principal and to any co-agent, successor agent, monitor if one has been named in this document, or the principal's guardian if one has been appointed. If there is anything about this document or your responsibilities that you do not understand, you should seek legal advice. Liability of agent: The meaning of the authority given to you is defined in New York's General Obligations Law, Article 5, Title 15. If it is found that you have violated the law or acted outside the authority granted to you in the Power of Attorney, you may be liable under the law for your violation. AGENT'S SIGNATURE AND ACKNOWLEDGMENT OF APPOINTMENT:It is not required that the principal and the agent(s) sign at the same time, nor that multiple agents sign at the same time. I, ________________________________, have read the foregoing Power of Attorney. I am the person identified therein as agent for the principal named therein. I acknowledge my legal responsibilities. Agent signs here: ► __________________________________ _______________________________________________ Type or Print Name _______________________________________ _______________________________________________ Type or Print Name Individual Capacity within the State of New York State of New York, County of __________________, ss On the ______ day of __________________ in the year ____________ before me, the undersigned, personally appeared ________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity, and that by his signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Signature and Office of Person Taking Acknowledgement Type/Print Name: __________________________ Individual Capacity Outside the State of New York State of __________________, County of __________________, ssOn the ______ day of __________________ in the year ____________ before me, the undersigned, personally appeared ______________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity, and that by his signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument and that such individual made such appearance before the undersigned in the ________________________ (insert the city or other political subdivision and the State or country or other place the acknowledgment was taken). Signature and Office of Person Taking Acknowledgement Type/Print Name: __________________________ SUCCESSOR AGENT'S SIGNATURE AND ACKNOWLEDGMENT OF APPOINTMENT: It is not required that the principal and the successor agent(s), if any, sign at the same time, nor that multiple successor agents sign at the same time. Furthermore, successor agents can not use this power of attorney unless the agent(s) designated above is/are unable or unwilling to serve. I/ we, ________________________ have read the foregoing power of attorney. I am/we are the person(s) identified therein as Successor agent(s) for the principal named therein. Successor agent(s) sign(s) here:==> ___________________________ Successor agent(s) sign(s) here:==> ___________________________ Individual Capacity within the State of New York State of New York, County of __________________, ss On the ______ day of __________________ in the year ____________ before me, the undersigned, personally appeared ________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity, and that by his signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Signature and Office of Person Taking Acknowledgement Type/Print Name: __________________________ Individual Capacity Outside the State of New York State of __________________, County of __________________, ss On the ______ day of __________________ in the year ____________ before me, the undersigned, personally appeared ______________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity, and that by his signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument and that such individual made such appearance before the undersigned in the ________________________ (insert the city or other political subdivision and the State or country or other place the acknowledgment was taken). Signature and Office of Person Taking Acknowledgement Type/Print Name: __________________________ SIGNATURES OF WITNESSES: By signing as a witness, I acknowledge that the principal signed this document in my presence and the presence of the other witness, or that the principal acknowledged to me that the principal’s signature was affixed by him or her or at his or her direction. I also acknowledge t hat the principal has stated that this document reflects his or her wishes and that he or she has signed it voluntarily. ___________________________ _________________________ Signature of witness 1 Signature of witness 2 __________________________ __________________________ Date Date __________________________ __________________________ Print name Print name __________________________ __________________________ Address Address __________________________ __________________________ City, State, Zip code City, State, Zip code