Fill and Sign the Specific Power Attorney Form

Specific Power of Attorney BE IT ACKNOWLEDGED that I, ___________________________________ Full Name ________________________________, the undersigned, do hereby grant a limited and social security number specific power of attorney to _______________________________________________ Full Name of ___________________________________________________________________ Address Phone as my attorney-in-fact. Said attorney-in-fact shall have full power and authority to undertake and perform only the following acts on my behalf: 1. _______________________________________________________________ 2. _______________________________________________________________ 3. _______________________________________________________________ The authority herein shall include such incidental acts as are reasonably required to carry out and perform the specific authorities granted herein. My attorney-in-fact agrees to accept this appointment subject to its terms, and agrees to act and perform in said fiduciary capacity consistent with my best interest, as my attorney-in-fact in its discretion deems advisable. This power of attorney is effective upon execution. This power of attorney may be revoked by me at any time, and shall automatically be revoked upon my death, provided any person relying on this power of attorney shall have full rights to accept and reply upon the authority of my attorney-in-fact until in receipt of actual notice of revocation. Signed this ______________ day of ___________________, 20_____. ___________________________________ Signature