I, __________, of __________, appoint __________ as my agent (attorney-in-fact). If my agent cannot serve, I appoint __________.

1. Powers

My agent may act for me in all financial matters, including banking, real estate transactions, buying and selling property, paying bills, filing taxes, managing investments, dealing with government benefits and handling insurance.

2. Effective Date

This power of attorney takes effect: __________.

3. Durability

This power of attorney shall not be affected by my subsequent disability or incapacity.

Revocation

I may revoke this power of attorney at any time by written notice to my agent.

Notary Acknowledgment

State of __________, County of __________.

On ____________________, before me, the undersigned notary public, personally appeared __________, proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to this instrument, and acknowledged that he/she/they executed the same.

Notary Public Signature: ______________________________ My Commission Expires: ____________