© 2016 - U.S. Legal Forms, Inc.
NEW YORK
STATUTORY DURABLE POWER OF
ATTORNEY
[includes Gifts Rider]
Control Number: NY-P012
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GENERAL POWER OF ATTORNEY
NEW YORK STATUTORY SHORT FORM
(New York State Consolidated Laws, General Obligations, §§ 5-1501 and 5-1513)
THE POWERS YOU GRANT BELOW CONTINUE TO BE EFFECTIVE
SHOULD YOU BECOME DISABLED OR INCOMPETENT UNLESS YOU STATE
OTHERWISE IN THE “MODIFICATIONS” SECTION AT PAGE 4.
THIS is intended to constitute a STATUTORY GENERAL POWER OF ATTORNEY pursuant
to Article 5, Title 15 of the New York General Obligations Law:
A. 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, YOU SHOULD
PROVIDE WRITTEN NOTICE OF THE REVOCATION TO YOUR PRIOR AGENT(S)
AND TO ANY THIRD PARTIES WHO HAVE RELIED ON IT, INCLUDING 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.
Durable General Power of Attorney
Page 1 of 10
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.
B. DESIGNATION OF AGENT(S)
I, ____________________________________________________________________________________
(insert your name and address)
do hereby appoint:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
(insert name(s) and address(es) of agent(s)
If you designate more than one agent above, they must act together unless you initial the
statement below.
(______) My agents may act separately.
C. DESIGNATION OF SUCCESSOR AGENT(S)
(OPTIONAL)
If any agent designated above is unable or unwilling to serve, I appoint as my successor agent(s):
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
(insert name(s) and address(es) of successor agent(s))
Successor agents designated above must act together unless you initial the statement below.
(______) My successor agents may act SEPARATELY.
Durable General Power of Attorney
Page 2 of 10
YOU MAY PROVIDE FOR SPECIFIC SUCCESSION RULES IN THIS SECTION. INSERT
SPECIFIC SUCCESSION PROVISIONS HERE:
_____________________________________________________________________________
D. EFFECT OF SUBSEQUENT INCAPACITY
This power of attorney shall not be affected by my subsequent incapacity unless I have
stated otherwise below, under "Modifications".
E. REVOCATION OF PRIOR POWERS OF ATTORNEY
This power of attorney does not revoke any powers of attorney previously executed by
me unless I have stated otherwise below, under "modifications." if you do not intend to revoke
your prior powers of attorney, and if you have granted the same authority in this power of
attorney as you granted to another agent in a prior power of attorney, each agent can act
separately unless you indicate under "modifications" that the agents with the same authority are
to act together.
F. GRANT OF AUTHORITY
To grant your agent some or all of the authority below, either
(1) Initial the bracket at each authority you grant, or
(2) Write or type the letters for each authority you grant on the blank line at (P), and
initial the bracket at (P). If you initial (P), you do not need to initial the other lines.
I grant authority to my agent(s) with respect to the following subjects as defined in sections 5-
1502A through 5-1502N of the New York General Obligations Law:
(___) (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;
Durable General Power of Attorney
Page 3 of 10
(___) (H) claims and litigation;
(___) (I) personal and family maintenance. IF YOU GRANT YOUR AGENT THIS
AUTHORITY, IT WILL ALLOW THE AGENT TO MAKE GIFTS THAT YOU
CUSTOMARILY HAVE MADE TO INDIVIDUALS, INCLUDING THE AGENT,
AND CHARITABLE ORGANIZATIONS. THE TOTAL AMOUNT OF ALL SUCH
GIFTS IN ANY ONE CALENDAR YEAR CANNOT EXCEED FIVE HUNDRED
DOLLARS;
(___) (J) benefits from governmental programs or civil or military
service;
(___) (K) health care billing and payment matters; records, reports,
and statements;
(___) (L) retirement benefit transactions;
(___) (M) tax matters;
(___) (N) all other matters;
(___) (O) full and unqualified authority to my agent(s) to delegate any or all of the
foregoing powers to any person or persons whom my agent(s) select;
(___) (P) each of the matters identified by the following letters:
_____________________________________________________ .
You need not initial the other lines if you initial line (P).
G. MODIFICATIONS: (OPTIONAL):
In this section, you may make additional provisions, including language to limit or
supplement authority granted to your agent.
However, you cannot use this Modifications section to grant your agent authority to make
gifts or changes to interests in your property. If you wish to grant your agent such authority, you
MUST complete the Statutory Gifts Rider.
I hereby make the following “Modifications” herein:
Durable General Power of Attorney
Page 4 of 10
(H) CERTAIN GIFT TRANSACTIONS: STATUTORY GIFTS RIDER
(OPTIONAL)
In order to authorize your agent to make gifts in excess of an annual total of $500 for all
gifts described in (i) of the grant of authority section of this document (under personal and family
maintenance), you must initial the statement below and execute a Statutory Gifts Rider at the
same time as this instrument. Initialing the statement below by itself does not authorize your
agent to make gifts. The preparation of the Statutory Gifts Rider should be supervised by a
lawyer.
(___) (SGR) I grant my agent authority to make gifts in accordance with the terms and
conditions of the Statutory Gifts Rider that supplements this Statutory Power of Attorney.
I. DESIGNATION OF MONITOR(S): (OPTIONAL)
I wish to designate, ________________________________________ ,
whose address is ________________________________________ ,
as monitor . Upon the request of the monitor , my agent must provide the monitor with a copy of
the power of attorney and a record of all transactions done or made on my behalf. Third parties
holding records of such transactions shall provide the records to the monitor upon request.
J. COMPENSATION OF AGENT(S): (OPTIONAL)
Your agent is entitled to be reimbursed from your assets for reasonable expenses incurred
on your behalf. If you ALSO wish your agent(s) to be compensated from your assets for services
rendered on your behalf, initial the statement below. If you wish to define "reasonable
compensation", you may do so above, under "Modifications".
(___) My agent(s) shall be entitled to reasonable compensation for services rendered.
K. ACCEPTANCE BY THIRD PARTIES:
I agree to indemnify the third party for any claims that may arise against the third party
because of reliance on this Power of Attorney. I understand that any termination of this Power of
Attorney, whether the result of my revocation of the Power of Attorney or otherwise, is not
Durable General Power of Attorney
Page 5 of 10
effective as to a third party until the third party has actual notice or knowledge of the
termination.
L. TERMINATION:
This Power of Attorney continues until I revoke it or it is terminated by my death or other
event described in section 5-1511 of the General Obligations Law.
Section 5-1511 of the General Obligations Law describes the manner in which you may
revoke your Power of Attorney, and the events which terminate the Power of Attorney.
M. 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
Durable General Power of Attorney
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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:
N. 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.
Durable General Power of Attorney
Page 7 of 10
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.
O. 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
Durable General Power of Attorney
Page 8 of 10
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:
(P) 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
Durable General Power of Attorney
Page 9 of 10
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:
Durable General Power of Attorney
Page 10 of 10
POWER OF ATTORNEY - NEW YORK STATUTORY MAJOR GIFTS RIDER
AUTHORIZATION TO MAKE MAJOR GIFTS OR OTHER TRANSFERS
A. CAUTION TO THE PRINCIPAL!
This OPTIONAL rider allows you to authorize your agent to make major gifts or other
transfers of your money or other property during your lifetime. Granting any of the following
authority to your agent gives your agent the authority to take actions which could significantly
reduce your property or change how your property is distributed at your death. "Major gifts or
other transfers" are described in section 5-1514 of the General Obligations Law. This Major
Gifts Rider does not require your agent to exercise granted authority, but when he or she
exercises this authority, he or she must act according to any instructions you provide, or
otherwise in your best interest.
This Major Gifts Rider and the Power of Attorney it supplements must be read together
as a single instrument.
Before signing this document authorizing your agent to make major gifts and other
transfers, you should seek legal advice to ensure that your intentions are clearly and properly
expressed.
B. GRANT OF LIMITED AUTHORITY TO MAKE GIFTS
Granting gifting authority to your agent gives your agent the authority to take actions
which could significantly reduce your property.
If you wish to allow your agent to make gifts to himself or herself, you must separately
grant that authority in subdivision (c) below.
To grant your agent the gifting authority provided below, initial the bracket to the left of
the authority.
(____) I grant authority to my agent to make gifts to my spouse, children and more
remote descendants, and parents, not to exceed, for each donee, the annual federal gift tax
exclusion amount pursuant to the Internal Revenue Code. For gifts to my children and more
remote descendants, and parents, the maximum amount of the gift to each donee shall not exceed
twice the gift tax exclusion amount, if my spouse agrees to split gift treatment pursuant to the
Internal Revenue Code. This authority must be exercised pursuant to my instructions, or
otherwise for purposes which the agent reasonably deems to be in my best interest.
C. MODIFICATIONS:
Use this section if you wish to authorize gifts in excess of the above amount, gifts to
other beneficiaries or other types of transfers. Granting such authority to your agent gives your
agent the authority to take actions which could significantly reduce your property and/or change
how your property is distributed at your death. If you wish to authorize your agent to make gifts
New York Statutory Major Gifts Rider
Page 1 of 4
or transfers to himself or herself, you must separately grant that authority in subdivision (c)
below.
(____) I grant the following authority to my agent to make gifts or transfers pursuant to
my instructions, or otherwise for purposes which the agent reasonably deems to be in my best
interest.
D. GRANT OF SPECIFIC AUTHORITY FOR AN AGENT TO MAKE MAJOR GIFTS
OR OTHER TRANSFERS TO HIMSELF OR HERSELF: (OPTIONAL)
If you wish to authorize your agent to make gifts or transfers to himself or herself, you
must grant that authority in this section, indicating to which agent(s) the authorization is granted,
and any limitations and guidelines.
(_____) I grant specific authority for the following agent(s) to make the following major
gifts or other transfers to himself or herself: This authority must be exercised pursuant to my
instructions, or otherwise for purposes which the agent reasonably deems to be in my best
interest.
E. ACCEPTANCE BY THIRD PARTIES:
I agree to indemnify the third party
for any claims that may arise against the third party because of reliance
on this Major Gifts Rider.
F. SIGNATURE OF PRINCIPAL AND ACKNOWLEDGMENT:
In Witness Whereof I have hereunto signed my name on ________________________ ,
20 _______ .
Principal signs here: ►
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.
New York Statutory Major Gifts Rider
Page 2 of 4
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:
G. SIGNATURES OF WITNESSES:
By signing as a witness, I acknowledge that the principal signed the Major Gifts Rider 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
that the principal has stated that this Major Gifts Rider reflects his or her wishes and that he or
she has signed it voluntarily. I am not named herein as a permissible recipient of major gifts.
Signature of witness 1 Signature of witness 2
Date Date
New York Statutory Major Gifts Rider
Page 3 of 4
Print name Print name
Address Address
City, State, Zip code City, State, Zip code
H. This document prepared by: ________________________________________
New York Statutory Major Gifts Rider
Page 4 of 4
"POWER OF ATTORNEY NEW YORK STATUTORY GIFTS RIDER
AUTHORIZATION FOR CERTAIN GIFT TRANSACTIONS CAUTION TO THE
PRINCIPAL:
This optional rider allows you to authorize your agent to make gifts in excess of an annual total
of $500 for all gifts described in (i) of the grant of authority section of the statutory short form
power of attorney (under personal and family maintenance), or certain other gift transactions
during your lifetime. you do not have to execute this rider if you only want your agent to make
gifts described in (i) of the grant of authority section of the statutory short form power of
attorney and you initialed "(i)" on that section of that form. Granting any of the following
authority to your agent gives your agent the authority to take actions which could significantly
reduce your "certain gift transactions" are described in section 5-1514 of the General Obligations
Law. This Gifts Rider does not require your agent to exercise granted authority, but when he or
she exercises this authority, he or she must act according to any instructions you provide, or
otherwise in your best interest.
This Gifts Rider and the Power of Attorney it supplements must be read together as a single
instrument.
Before signing this document authorizing your agent to make gifts, you should seek legal
advice to ensure that your intentions are clearly and properly expressed.
(a) GRANT OF LIMITED AUTHORITY TO MAKE GIFTS Granting gifting authority to your
agent gives your agent the authority to take actions which could significantly reduce your
property.
If you wish to allow your agent to make gifts to himself or herself, you must separately grant
that authority in subdivision (c) below.
To grant your agent the gifting authority provided below, initial the bracket to the left of the
authority.
( ) I grant authority to my agent to make gifts to my spouse, children and more remote
descendants, and parents, not to exceed, for each donee, the annual federal gift tax exclusion
amount pursuant to the Internal Revenue Code. For gifts to my children and more remote
descendants, and parents, the maximum amount of the gift to each donee shall not exceed twice
the gift tax exclusion amount, if my spouse agrees to split gift treatment pursuant to the Internal
Revenue Code. This authority must be exercised pursuant to my instructions, or otherwise for
purposes which the agent reasonably deems to be in my best interest.
(b) MODIFICATIONS:
Use this section if you wish to authorize gifts in amounts smaller than the gift tax exclusion
amount, in amounts in excess of the gift tax exclusion amount, gifts to other beneficiaries, or
other gift transactions. Granting such authority to your agent gives your agent the authority to
take actions which could significantly reduce your property and/or change how your property is
New York Statutory Major Gifts Rider
Page 1 of 3
distributed at your death. If you wish to authorize your agent to make gifts to himself or herself,
you must separately grant that authority in subdivision (c) below.
( ) I grant the following authority to my agent to make gifts pursuant to my instructions, or
otherwise for purposes which the agent reasonably deems to be in my best interest.:
(c) GRANT OF SPECIFIC AUTHORITY FOR AN AGENT TO MAKE GIFTS TO HIMSELF
OR HERSELF: (OPTIONAL)
If you wish to authorize your agent to make gifts to himself or herself, you must grant that
authority in this section, indicating to which agent(s) the authorization is granted, and any
limitations and guidelines.
( ) I grant specific authority for the following agent(s) to make the following gifts to himself or
herself: This authority must be exercised pursuant to my instructions, or otherwise for purposes
which the agent reasonably deems to be in my best interest.
(d) ACCEPTANCE BY THIRD PARTIES: I agree to indemnify the third party for any claims
that may arise against the third party because of reliance on this statutory Gifts Rider.
(e) SIGNATURE OF PRINCIPAL AND ACKNOWLEDGMENT:
In Witness Whereof I have hereunto signed my name on ____________________________ ,
20 _______ .
PRINCIPAL signs here:
____________________________________________
(ACKNOWLEDGMENT)
(f) SIGNATURES OF WITNESSES: By signing as a witness, I acknowledge that the principal
signed the statutory Gifts Rider 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 that the principal has stated that this statutory Gifts Rider
reflects his or her wishes and that he or she has signed it voluntarily. I am not named herein as a
permissible recipient of gifts.
___________________________ _________________________
Signature of witness 1 Signature of witness 2
___________________________ _________________________
Date Date
____________________________ _ ____________________________
Print name Print name
New York Statutory Major Gifts Rider
Page 2 of 3
____________________________ ____________________________
Address Address
____________________________ ____________________________
City, State, Zip code City, State, Zip code
(g) This document prepared by: ____________________________
New York Statutory Major Gifts Rider
Page 3 of 3
