Fill and Sign the State Zip Principal Have Made Constituted and Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only--------------------- Name: Company: Address: City: State: Zip: Phone: Fax: The information above is provided in the event this form is to be recorded. LIMITED POWER OF ATTORNEY STATE OF INDIANA COUNTY OF ____________ KNOW ALL MEN BY THESE PRESENT, THAT I __________________________________, whose address is ___________________________________, _________________ (City), __________________ (State), ________ (Zip), “Principal”, have made, constituted and appointed, and by these presents do make, constitute and appoint, ____________________________ my true and lawful attorney in fact to act with the following limited powers, to wit: Insert powers here. See examples at the end of this form ___________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ FURTHER, I do authorize my aforesaid attorney-in-fact to execute, acknowledge and deliver any instrument under seal or otherwise, and to do all things necessary to carry out the intent hereof, hereby granting unto my said attorney-in-fact full power and authority to act in and concerning the premises as fully and effectually as I may do if personally present, limited, however, to the purpose for which this limited power of attorney is executed. PROVIDED, however, that all business transacted hereunder for me or for my account shall be transacted in my name, and that all endorsements and instruments executed by my said attorney-in-fact for the purpose of carrying out the foregoing powers shall contain my name,
Name and signature and the words "limited power of attorney”, with any other names and signatures that may be signed by or on my behalf. The signing of any such instrument shall be prima facie evidence that each person therein named and intended to be bound thereby has acted therein with the power to bind all persons. Section 7. (2) any person or entity who does not enter into an agreement to act for me or to deliver any information or other document to me, must be deemed to agree to any and all liabilities, if any, that will arise and be imposed upon my account as follows: (i) to pay any and all sums due for my services or that shall be payable to me by any and all vendors. (ii) to be responsible for any and all loss, damages, fines or other sums owed to me by any person or entity for any and all breach by that person or entity of its obligations to deliver information or documents to me. (iii) the costs and expenses of any and all actions, remedies and proceedings that I may take against, against any and all persons and entities who have not entered into an agreement to act for or deliver information or other documents to me to satisfy my liability imposed under this section. (iv) to cooperate with any and all government agencies and other entities and agencies as requested to enforce my liability and, if so selected, whether to comply with the provisions of chapter 21, article 3 of the civil practice law and rules of procedure of the state of Indiana. (v) if any person or entity does not consent to be bound by this agreement or if my liability is unsatisfied under the law of the state of Indiana, then to use my personal attorney and a private attorney to enforce my liability. (vi) a written or oral undertaking, statement or agreement by any and all such persons or entities as to not do anything that is prohibited by the terms of this agreement. (vii) to indemnify, defend and hold harmless me, my attorney and the private attorney against the consequences of, or actions taken or omitted to be taken or omitted by them, or any of them acting in concert with me, in any action or proceeding against us and our respective property that arises from, is connected to or is related to, any breach by any person or entity in connection with it. (viii) to have all of my legal, administrative, accounting, tax and credit records made available to my designated