Fill and Sign the Vermont Being of Sound Mind and Memory Do Hereby Make Constitute and Appoint Form

SPECIAL DURABLE POWER OF ATTORNEY FOR BANK ACCOUNT MATTERS STATE OF VERMONTCOUNTY OF _________________ _ KNOW ALL MEN BY THESE PRESENTS: That I, _________________ _ of _________________ _ County, Vermont, 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, individually, 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), Vermont, ____________ (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 physically incapacitated or incapable of understanding or unable to express myself or act in my own behalf at the time of any action on my behalf by said agent. Such incapacity, whether mental or physical, that 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 my 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, regardless 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.IN WITNESS WHEREFORE, I have executed this Special Power of Attorney on this the _ _ day of _________________ _, 20___. Signed this ____ day of _________________ _, 20_____________________________________________________ Principal_________________ _City, County, and State of ResidenceI, _________________ _, witnessed the signature of the principal above and I affirm that the principal appeared to be of sound mind and free from duress at the time this power of attorney was signed and the principal affirmed to me that he or she was aware of the nature of the document and signed it freely and voluntarily. Witness: ______________________________________________________________________ Address: _________________ _Witness: ______________________________________________________________________ Address: _________________ _STATE OF VERMONTCOUNTY OF _________________ _ At _________________ _ (town or city) on _________________ _ (date) _________________ _ personally appeared and acknowledged the foregoing power of attorney to be his/her free act and deed. Before me- ___________________________________________ (Seal)(Signature of Person Taking Acknowledgment)_________________ _ (Title) My commission expires: _________________ _ I, _________________ _, agent named above attest that : (1) I accept appointment as agent; (2) I understand the duties I am assuming under this power of attorney under the law; (3) I understand that I have a duty to act if expressly required to do so in this power of attorney consistent with said 14 VSA Section 3506(c); and (4) I understand that I am expected to use my special skills or expertise on behalf of the principal as follows (insert any such special skills): Date_________________ _ _________________ _ Agent WITNESSES:______________________________SignaturePrint Name: ___________________________Address: _________________ _City: ___________ State: ___________ Zip: _______________WITNESSES:______________________________SignaturePrint Name: _________________ _Address: _________________ _ City: ___________ State: __________ Zip: _______________