Durable Unlimited Power of Attorney - effective immediately

Notice to Adult Signing this Document: This is an important document. Before signing this
document, you should know these important facts. By signing this document, you are not giving
up any powers or rights to control your finances and property yourself. In addition to your own
powers and rights, you are giving another person, your attorney-in-fact, broad powers to handle
your finances and property, which may include powers to encumber, sell or otherwise dispose of
any real or personal property without advance notice to you or approval by you. THE POWERS
GRANTED UNDER THIS DOCUMENT ARE EFFECTIVE IMMEDIATELY AND WILL
REMAIN IN EFFECT IF YOU BECOME DISABLED OR INCAPACITATED. This document
does not authorize anyone to make medical or other health care decisions for you. If you own
complex or special assets such as a business, or if there is anything about this form that you do
not understand, you should ask a lawyer to explain this form to you before you sign it. If you
wish to change your durable unlimited power of attorney, you must complete a new document
and revoke this one. You have the right to revoke the designation of the attorney-in-fact and the
right to revoke this entire document at any time and in any manner. You may revoke this
document at any time by destroying it, by directing another person to destroy it in your presence
or by signing a written and dated statement expressing your intent to revoke this document. If
you revoke this document, you should notify your attorney-in-fact and any other person to whom
you have given a copy of the form. You also should notify all parties having custody of your
assets. These parties have no responsibility to you unless you actually notify them of the
revocation. If your attorney-in-fact is your spouse and your marriage is annulled, or you are
divorced after signing this document, this document may become invalid. Since some third
parties or some transactions may not permit use of this document, it is advisable to check in
advance, if possible, for any special requirements that may be imposed. You should sign this
form only if the attorney-in- fact you name is reliable, trustworthy and competent to manage your
affairs. Generally, you may designate any competent adult as the attorney-in-fact under this
document. 

I, * (printed name), of  (address) *, as principal, do appoint *  (printed name), of (address) *, as my
attorney-in- fact to act in my name, place and stead in any way which I myself could do, if I were
personally present, with respect to all of the following matters to the extent that I am permitted by
law to act through an agent: I grant my attorney-in-fact the maximum power under law to perform
any act on my behalf that I could do personally, including but not limited to, all acts relating to any
and all of my financial transactions and/or business affairs including all banking and financial
institution transactions, all real estate or personal property transactions, all insurance or annuity
transactions, all claims and litigation, and any and all business transactions. This power of attorney
shall become effective immediately and shall remain in full effect upon my disability or
incapacitation. This power of attorney grants no power or authority regarding healthcare decisions
to my designated attorney-in-fact.

If the attorney-in-fact named above is unable or unwilling to serve, then I appoint  * (printed name),
of *  (address), to be my successor attorney-in-fact for all purposes hereunder.

My attorney-in-fact is granted full and unlimited power to act on my behalf in the same manner as
if I were personally present. My attorney-in-fact accepts this appointment and agrees to act in my
best interest as he or she considers advisable. To induce any third party to rely upon this power of
attorney, I agree that any third party receiving a signed copy or facsimile of this power of attorney
may rely upon such copy, and that revocation or termination of this power of attorney shall be
ineffective as to such third party until actual notice or knowledge of such revocation or termination
shall have been received by such third party. I, for myself and for my heirs, executors, legal
representatives and assigns, agree to indemnify and hold harmless any such third party from any and
all claims that may arise against such third party by reason of such third party having relied on the
provisions of this power of attorney. This power of attorney may be revoked by me at any time and
is automatically revoked upon my death. My attorney-in-fact shall not be compensated for his or her
services nor shall my attorney-in-fact be liable to me, my estate, heirs, successors, or assigns for
acting or refraining from acting under this document, except for willful misconduct or gross
negligence. Revocation of this document is not effective unless a third party has actual knowledge
of such revocation. I intend for my attorney-in-fact under this Power of Attorney to be treated as I
would be with respect to my rights regarding the use and disclosure of my individually identifiable
health information or other medical records. This release authority applies to any information
governed by the Health Insurance Portability and Accountability Act of 1996 (aka HIPAA), 42 USC
1320d and 45 CFR 160-164.

Signature and Declaration of Principal
I, * (printed name), the principal, sign my name to this power of attorney this * day of * and, being
first duly sworn, do declare to the undersigned authority that I sign and execute this instrument as
my power of attorney and that I sign it willingly, or willingly direct another to sign for me, that I
execute it as my free and voluntary act for the purposes expressed in the power of attorney and that
I am eighteen years of age or older, of sound mind and under no constraint or undue influence ,and
that I have read and understand the contents of the notice at the beginning of this document.
*
Signature of Principal

Witness Attestation
I, * (printed name), the first witness, and I, * (printed name), the second witness, sign my name to
the foregoing power of attorney being first duly sworn and do declare to the undersigned authority
that the principal signs and executes this instrument as his/her power of attorney and that he/she
signs it willingly, or willingly directs another to sign for him/her, and that I, in the presence and
hearing of the principal, sign this power of attorney as witness to the principal's signing and that to
the best of my knowledge the principal is eighteen years of age or older, of sound mind and under
no constraint or undue influence.
*      
Signature of First Witness 
*
Signature of Second Witness

Notary Acknowledgment
The State of *
County of *
Subscribed, sworn to and acknowledged before me by * , the principal, and subscribed and sworn
to before me by* , the first witness, and * , the second witness on this date * .
*
Notary Public Signature
Notary Public, In and for the County of * 
State of *
My commission expires: *        Notary Seal

Acknowledgment and Acceptance of Appointment as Attorney-in-Fact
I, *, (printed name) have read the attached power of attorney and am the person identified as the
attorney-in-fact for the principal. I hereby acknowledge that I accept my appointment as attorney-in-
fact and that when I act as agent I shall exercise the powers for the benefit of the principal; I shall
keep the assets of the principal separate from my assets; I shall exercise reasonable caution and
prudence; and I shall keep a full and accurate record of all actions, receipts and disbursements on
behalf of the principal.

*     
Signature of Attorney-in-Fact                       
*Date

Acknowledgment and Acceptance of Appointment as Successor Attorney-in-Fact
I, *, (printed name) have read the attached power of attorney and am the person identified as the
successor attorney-in-fact for the principal. I hereby acknowledge that I accept my appointment as
successor attorney-in-fact and that, in the absence of a specific provision to the contrary in the power
of attorney, when I act as agent I shall exercise the powers for the benefit of the principal; I shall
keep the assets of the principal separate from my assets; I shall exercise reasonable caution and
prudence; and I shall keep a full and accurate record of all actions, receipts and disbursements on
behalf of the principal.

*
Signature of Successor Attorney-in-Fact                  
*Date