Limited Power of Attorney

Notice: 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 may be
giving another person, your attorney-in-fact, broad powers to handle your finances and property.
This limited power of attorney may give the person whom you designate (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 WILL NOT EXIST AFTER 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 limited power of attorney, you must
complete a new document and revoke this one. 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 is invalid. Since some 3rd 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 that you appoint is reliable,
trustworthy and competent to manage your affairs. This form must be signed by the Principal (the
person appointing the attorney-in-fact), witnessed by two persons other than the notary public,
and acknowledged by a notary public.


 I, * (printed name), of (address)*, as principal, do grant a limited and specific power of attorney to,
and do hereby appoint * (printed name), of (address) * , to act as my attorney-in-fact and to have the
full power and authority to perform only the following acts on my behalf to the same extent that I
could do so personally if I were personally present, with respect to the following matter to the extent
that I am permitted by law to act through an agent: (list specific acts) *



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

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 shall not be effective in the event of my future disability or incapacity. This
limited grant of authority does not authorize my attorney-in-fact to make any decisions regarding my
medical or health care. 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. My attorney-in-fact accepts this appointment and agrees to act in my best interest as he
or she considers advisable. This grant of authority shall include the power and authority to perform
any incidental acts which may be reasonably required in order to perform the specific acts stated
above.

Dated: *

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.
*
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

State of *  
County of *
Subscribed, sworn to and acknowledged before me by *,  the Principal, and subscribed and sworn
to before me by * , and * , the witnesses, this*  day of * .

*
Notary Signature
Notary Public,
In and for the County of * State of *
                                                         My commission expires: *                                  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