Limited Power of Attorney
BE IT ACKNOWLEDGED that I, ________________________________
Full Name
_____________________________, the “Principal”, do hereby grant a limited
social security number
and specific power of attorney to ____________________________________ of
Full Name
________________________________________________________________________
Address Phone
as my “Attorney-in-Fact”.
Said Attorney-in-Fact shall have full power and authority to undertake and
perform only the following acts on my behalf:
1. _______________________________________________________________
2. _______________________________________________________________
3. _______________________________________________________________
The authority herein shall include such incidental acts as are reasonably required
to carry out and perform the specific authorities granted herein. My Attorney-in-
Fact agrees to accept this appointment subject to its terms, and agrees to act and
perform in said fiduciary capacity consistent with my best interest, as my Attorney-
in-Fact in its discretion deems advisable. This power of attorney is effective upon
execution.
This power of attorney may be revoked by any of the following:
(Initial and Check the Box if Applicable)
______ ☐ - By the Principal at anytime by authorizing a Revocation.
______ ☐ - When the above stated one (1) time power or responsibility has been
completed.
______ ☐ - On the ____ day of _______________________, 20___.
This power of attorney form shall automatically be revoked upon my death or
incapacitation, provided any person relying on this power of attorney shall have full
rights to accept and reply upon the authority of my Attorney-in-Fact until in receipt
of actual notice of revocation.
State Law. This Power of Attorney is governed by the laws of the State of
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_______________________.
Signed this ____ day of _______________________, 20___.
___________________________
Signature
___________________________
Print Name
ACCEPTANCE OF APPOINTMENT
I, ________________________, the attorney-in-fact named above, hereby accept
appointment as attorney-in-fact in accordance with the foregoing instrument.
__________________________
Attorney-in-Fact’s Signature
__________________________
Attorney-in-Fact’s Printed Name
WITNESSES
We, the witnesses, each do hereby declare in the presence of the principal that the
principal signed and executed this instrument as his Power of Attorney in the presence of
each of us, that he signed it willingly, that each of us hereby signs this Power of Attorney
as witness at the request of the principal and in his presence, and that, to the best of our
knowledge, the principal is eighteen years of age or over, of sound mind, and under no
constraint or undue influence.
____________________ _____________________________________
Witness Signature Address
____________________ _____________________________________
Witness Print Name City, State & Zip Code
____________________ _____________________________________
Witness Signature Address
____________________ _____________________________________
Witness Print Name City, State & Zip Code
ACKNOWLEDGMENT OF NOTARY PUBLIC
STATE OF _______________
_____________ County, ss.
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On this ____ day of _______________________, 20___, before me appeared
____________________, as Principal of this Power of Attorney who proved to me through
government issued photo identification to be the above-named person, in my presence
executed foregoing instrument and acknowledged that he executed the same as his free
act and deed.
____________________________
Notary Public
My commission expires:_________
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