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Special Power of Attorney (United States)

This is a special power of attorney. The form provided here is simply a sample of what the actual form looks like.

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)_______, ____(6)_, and shall remain in full force and effect until

__________(7)_______________ or unless specifically extended or rescinded earlier by either party.

Dated ___________(8)______________, ____(9)_.

____________(10)______________

STATE OF _______(11)____________

COUNTY OF ______(12)____________

BEFORE ME, the undersigned authority, on this

_(13)_ day of _______(14)________, 20_(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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