A document substantially in the following form may be used to create a statutory form power of attorney that has the meaning and effect prescribed by this chapter.

     This power of attorney authorizes another person (your agent) to make decisions concerning your property for you (the principal). Your agent will be able to make decisions and act with respect to your property (including your money) whether or not you are able to act for yourself. The meaning of authority over subjects listed on this form is explained in Title 75A, Chapter 2, Uniform Power of Attorney Act.

     This power of attorney does not authorize the agent to make health care decisions for you.

     You should select someone you trust to serve as your agent. Unless you specify otherwise, generally the agent’s authority will continue until you die or revoke the power of attorney, or the agent resigns or is unable to act for you.

     Your agent is entitled to reasonable compensation unless you state otherwise in the Special Instructions.

     This form provides for designation of one agent. If you wish to name more than one agent you may name a coagent in the Special Instructions. Coagents are not required to act together unless you include that requirement in the Special Instructions.

     If your agent is unable or unwilling to act for you, your power of attorney will end unless you have named a successor agent. You may also name a second successor agent.

     This power of attorney becomes effective immediately unless you state otherwise in the Special Instructions.

     If you have questions about the power of attorney or the authority you are granting to your agent, you should seek legal advice before signing this form.

I ________________________________________________________ name the following

               (Name of Principal)

person as my agent:

Name of Agent:____________________________________________________________

Agent’s Address:___________________________________________________________

Agent’s Telephone Number:__________________________________________________

If my agent is unable or unwilling to act for me, I name as my successor agent:

Name of Successor Agent:____________________________________________

Successor Agent’s Address: ________________________________________

Successor Agent’s Telephone Number:___________________________________

If my successor agent is unable or unwilling to act for me, I name as my second successor agent:

Name of Second Successor Agent: _____________________________________

Second Successor Agent’s Address: __________________________________

Second Successor Agent’s Telephone Number: __________________________

I grant my agent and any successor agent general authority to act for me with respect to the following subjects as defined in Title 75A, Chapter 2, Uniform Power of Attorney Act:

(INITIAL each subject you want to include in the agent’s general authority. If you wish to grant general authority over all of the subjects you may initial “All Preceding Subjects” instead of initialing each subject.)

(___) Real Property

(___) Tangible Personal Property

(___) Stocks and Bonds

(___) Commodities and Options

(___) Banks and Other Financial Institutions

(___) Operation of Entity or Business

(___) Insurance and Annuities

(___) Estates, Trusts, and Other Beneficial Interests

(___) Claims and Litigation

(___) Personal and Family Maintenance

(___) Benefits from Governmental Programs or Civil or Military Service

(___) Retirement Plans

(___) Taxes

(___) All Preceding Subjects

My agent MAY NOT do any of the following specific acts for me UNLESS I have INITIALED the specific authority listed below:

(CAUTION: Granting any of the following will give your agent the authority to take actions that could significantly reduce your property or change how your property is distributed at your death. INITIAL ONLY the specific authority you WANT to give your agent.)

(___) Create, amend, revoke, or terminate an inter vivos trust

(___) Make a gift, subject to the limitations of Section 75A-2-217, and any special instructions in this power of attorney

(___) Create or change rights of survivorship

(___) Create or change a beneficiary designation

(___) Authorize another person to exercise the authority granted under this power of attorney

(___) Waive the principal‘s right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan

(___) Exercise fiduciary powers that the principal has authority to delegate

(___) Disclaim or refuse an interest in property, including a power of appointment

An agent that is not my ancestor, spouse, or descendant MAY NOT use my property to benefit the agent or a person to whom the agent owes an obligation of support unless I have included that authority in the Special Instructions.

You may give special instructions on the following lines:

____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

This power of attorney is effective immediately unless I have stated otherwise in the Special Instructions.

If it becomes necessary for a court to appoint a conservator of my estate or guardian of my person, I nominate the following person(s) for appointment:

Name of Nominee for conservator of my estate: _____________________________________

Nominee’s Address:____________________________________________________________

Nominee’s Telephone Number:___________________________________________________

Name of Nominee for guardian of my person: _______________________________________

Nominee’s Address: ___________________________________________________________

Nominee’s Telephone Number:___________________________________________________

Any person, including my agent, may rely upon the validity of this power of attorney or a copy of it unless that person knows it has terminated or is invalid.

____________________________________________ _______________

Your Signature                              Date

____________________________________________

Your Name Printed

____________________________________________

____________________________________________

Your Address

____________________________________________

Your Telephone Number

State of ____________________________

County of___________________________

This document was acknowledged before me on __________________________,

                                        (Date)

by______________________________________.

(Name of Principal)

____________________________________________ (Seal, if any)

Signature of Notary

My commission expires: ________________________

[This document prepared by:

__________________________________________________________________

__________________________________________________________________]

Agent’s Duties

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 upon you legal duties that continue until you resign or the power of attorney is terminated or revoked. You shall:

     (1) do what you know the principal reasonably expects you to do with the principal’s property or, if you do not know the principal’s expectations, act in the principal’s best interest;

     (2) act in good faith;

     (3) do nothing beyond the authority granted in this power of attorney; and

     (4) disclose your identity as an agent whenever you act for the principal by writing or printing the name of the principal and signing your own name as “agent” in the following manner:

(Principal’s Name) by (Your Signature) as Agent

Unless the Special Instructions in this power of attorney state otherwise, you must also:

     (1) act loyally for the principal’s benefit;

     (2) avoid conflicts that would impair your ability to act in the principal’s best interest;

     (3) act with care, competence, and diligence;

     (4) keep a record of all receipts, disbursements, and transactions made on behalf of the principal;

     (5) cooperate with any person that has authority to make health care decisions for the principal to do what you know the principal reasonably expects or, if you do not know the principal’s expectations, to act in the principal’s best interest; and

     (6) attempt to preserve the principal’s estate plan if you know the plan and preserving the plan is consistent with the principal’s best interest.

Termination of Agent’s Authority

You must stop acting on behalf of the principal if you learn of any event that terminates this power of attorney or your authority under this power of attorney. Events that terminate a power of attorney or your authority to act under a power of attorney include:

     (1) death of the principal;

     (2) the principal’s revocation of the power of attorney or your authority;

     (3) the occurrence of a termination event stated in the power of attorney;

     (4) the purpose of the power of attorney is fully accomplished; or

     (5) if you are married to the principal, a legal action is filed with a court to end your marriage, or for your legal separation, unless the Special Instructions in this power of attorney state that such an action will not terminate your authority.

Liability of Agent

The meaning of the authority granted to you is defined in Title 75A, Chapter 2, Uniform Power of Attorney Act. If you violate Title 75A, Chapter 2, Uniform Power of Attorney Act, or act outside the authority granted, you may be liable for any damages caused by your violation.

     If there is anything about this document or your duties that you do not understand, you should seek legal advice.