SPECIAL POWER OF
ATTORNEY
I, ___________(1)___________, of __________(2)_________, hereby appoint
______________(3)________________ of ___________(4)_______________, as my attorney in fact
to act in my capacity to do any and all of the following:
(DESCRIBE THE EXTENT OF AUTHORITY YOU ARE GIVING TO YOUR ATTORNEY-IN-FACT)
The rights, powers, and authority of my attorney in fact to exercise any and all of the
rights and powers herein granted shall commence and be in full force and effect on
____________(5)_______, 19__(6)_, and shall remain in full force and effect until
___________(7)_______________ or unless specifically extended or rescinded earlier by
either party.
Dated ___________(8)______________, 19__(9)_.
____________(10)______________
STATE OF _______(11)____________
COUNTY OF ______(12)____________
BEFORE ME, the undersigned authority, on this _(13)_ day of _______(14)________,
19_(15)_, personally appeared ___________(16)___________ to me well known to be the person
described in and who signed the Foregoing, and acknowledged to me that he executed the
same freely and voluntarily for the uses and purposes therein expressed.
WITNESS my hand and official seal the date aforesaid.
_________(17)___________________
NOTARY PUBLIC
My Commission Expires:__(18)____
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