N.Y. General Obligations Law § 5-1513: Statutory short form power of attorney

§ 5-1513. Statutory short form power of attorney. The use of the

following form, or one which substantially conforms to the following

form, in the creation of a power of attorney is lawful, and, when used,

and executed in accordance with subdivision one of section 5-1501B of

this title, it shall be construed as a statutory short form power of

attorney in accordance with the provisions of this title; provided

however, that any section indicated as "Optional" which is not used may

be omitted and replaced by the words "Intentionally Omitted":

"POWER OF ATTORNEY NEW YORK STATUTORY SHORT FORM

(a) CAUTION TO THE PRINCIPAL: Your Power of Attorney is an important

document. As the "principal," you give the person whom you choose (your

"agent") authority to spend your money and sell or dispose of your

property during your lifetime without telling you. You do not lose your

authority to act even though you have given your agent similar

authority.

When your agent exercises this authority, he or she must act according

to any instructions you have provided or, where there are no specific

instructions, in your best interest. "Important Information for the

Agent" at the end of this document describes your agent's

responsibilities.

Your agent can act on your behalf only after signing the Power of

Attorney before a notary public.

You can request information from your agent at any time. If you are

revoking a prior Power of Attorney, you should provide written notice of

the revocation to your prior agent(s) and to any third parties who may

have acted upon it, including the financial institutions where your

accounts are located.

You can revoke or terminate your Power of Attorney at any time for any

reason as long as you are of sound mind. If you are no longer of sound

mind, a court can remove an agent for acting improperly.

Your agent cannot make health care decisions for you. You may execute

a "Health Care Proxy" to do this.

The law governing Powers of Attorney is contained in the New York

General Obligations Law, Article 5, Title 15. This law is available at a

law library, or online through the New York State Senate or Assembly

websites, www.nysenate.gov or www.nyassembly.gov.

If there is anything about this document that you do not understand,

you should ask a lawyer of your own choosing to explain it to you.

(b) DESIGNATION OF AGENT(S):

I, _______________________________________________, hereby appoint:

name and address of principal

_____________________________________________________as my agent(s)

name(s) and address(es) of agent(s)

If you designate more than one agent above and you do not initial the

statement below, they must act together.

( ) My agents may act SEPARATELY.

(c) DESIGNATION OF SUCCESSOR AGENT(S): (OPTIONAL)

If any agent designated above is unable or unwilling to serve, I

appoint as my successor agent(s):

_______________________________________________________________

name(s) and address(es) of successor agent(s)

If you do not initial the statement below, successor agents designated

above must act together.

( ) My successor agents may act SEPARATELY.

You may provide for specific succession rules in this section. Insert

specific succession provisions here:

(d) This POWER OF ATTORNEY shall not be affected by my subsequent

incapacity unless I have stated otherwise below, under "Modifications".

(e) This POWER OF ATTORNEY DOES NOT REVOKE any Powers of Attorney

previously executed by me unless I have stated otherwise below, under

"Modifications."

(f) GRANT OF AUTHORITY:

To grant your agent some or all of the authority below, either

(1) Initial the bracket at each authority you grant, or

(2) Write or type the letters for each authority you grant on the

blank line at (P), and initial the bracket at (P). If you initial

(P), you do not need to initial the other lines.

I grant authority to my agent(s) with respect to the following

subjects as defined in sections 5-1502A through 5-1502N of the New

York General Obligations Law:

( ) (A) real estate transactions;

( ) (B) chattel and goods transactions;

( ) (C) bond, share, and commodity transactions;

( ) (D) banking transactions;

( ) (E) business operating transactions;

( ) (F) insurance transactions;

( ) (G) estate transactions;

( ) (H) claims and litigation;

( ) (I) personal and family maintenance. If you grant your agent

this authority, it will allow the agent to make gifts that you

customarily have made to individuals, including the agent, and

charitable organizations. The total amount of all such gifts in

any one calendar year cannot exceed five thousand dollars;

( ) (J) benefits from governmental programs or civil or military

service;

( )(K) financial matters related to health care; records, reports,

and statements;

( )(L) retirement benefit transactions;

( )(M) tax matters;

( )(N) all other matters;

( )(O) full and unqualified authority to my agent(s) to delegate

any or all of the foregoing powers to any person or persons whom

my agent(s) select;

( )(P) EACH of the matters identified by the following

letters______.

You need not initial the other lines if you initial line (P).

(g) CERTAIN GIFT TRANSACTIONS: (OPTIONAL)

In order to authorize your agent to make gifts in excess of an annual

total of $5,000 for all gifts described in (I) of the grant of authority

section of this document (under personal and family maintenance), and/or

to make changes to interest in your property, you must expressly grant

that authorization in the Modifications section below. If you wish to

authorize your agent to make gifts to himself or herself, you must

expressly grant such authorization in the Modifications section below.

Granting such authority to your agent gives your agent the authority to

take actions which could significantly reduce your property and/or

change how your property is distributed at your death. Your choice to

grant such authority should be discussed with a lawyer.

( ) I grant my agent authority to make gifts in accordance with the

terms and conditions of the Modifications that supplement this Statutory

Power of Attorney.

(h) MODIFICATIONS: (OPTIONAL)

In this section, you may make additional provisions, including, but

not limited to, language to limit or supplement authority granted to

your agent, language to grant your agent the specific authority to make

gifts to himself or herself, and/or language to grant your agent the

specific authority to make other gift transactions and/or changes to

interests in your property. Your agent is entitled to be reimbursed from

your assets for reasonable expenses incurred on your behalf. In this

section, you may make additional provisions if you ALSO wish your

agent(s) to be compensated from your assets for services rendered on

your behalf, and you may define "reasonable compensation."

(i) DESIGNATION OF MONITOR(S): (OPTIONAL)

If you wish to appoint monitor(s), initial and fill in the section

below:

( ) I wish to designate ______________________, whose address(es) is

(are) ____________________________________________________________, as

monitor(s). Upon the request of the monitor(s), my agent(s) must provide

the monitor(s) with a copy of the power of attorney and a record of all

transactions done or made on my behalf. Third parties holding records of

such transactions shall provide the records to the monitor(s) upon

request.

(j) COMPENSATION OF AGENT(S):

Your agent is entitled to be reimbursed from your assets for

reasonable expenses incurred on your behalf. If you ALSO wish your

agent(s) to be compensated from your assets for services rendered on

your behalf, and/or you wish to define "reasonable compensation", you

may do so above, under "Modifications".

(k) ACCEPTANCE BY THIRD PARTIES: I agree to indemnify the third party

for any claims that may arise against the third party because of

reliance on this Power of Attorney. I understand that any termination of

this Power of Attorney, whether the result of my revocation of the Power

of Attorney or otherwise, is not effective as to a third party until the

third party has actual notice or knowledge of the termination.

(l) TERMINATION: This Power of Attorney continues until I revoke it or

it is terminated by my death or other event described in section 5-1511

of the General Obligations Law.

Section 5-1511 of the General Obligations Law describes the manner in

which you may revoke your Power of Attorney, and the events which

terminate the Power of Attorney.

(m) SIGNATURE AND ACKNOWLEDGMENT: In Witness Whereof I have hereunto

signed my name on ___________,20___.

PRINCIPAL signs here: ==>__________________________________________

(acknowledgment)

(n) SIGNATURES OF WITNESSES:

By signing as a witness, I acknowledge that the principal signed the

Power of Attorney in my presence and in the presence of the other

witness, or that the principal acknowledged to me that the principal's

signature was affixed by him or her or at his or her direction. I also

acknowledge that the principal has stated that this Power of Attorney

reflects his or her wishes and that he or she has signed it voluntarily.

I am not named herein as an agent or as a permissible recipient of

gifts.

_____________________________________________________________

Signature of Witness 1 Signature of Witness 2

____________________________________________________________

Date Date

____________________________________________________________

Print name Print name

____________________________________________________________

Address Address

____________________________________________________________

City, State, Zip Code City, State, Zip Code

(o) IMPORTANT INFORMATION FOR THE AGENT:

When you accept the authority granted under this Power of Attorney, a

special legal relationship is created between you and the principal.

This relationship imposes on you legal responsibilities that continue

until you resign or the Power of Attorney is terminated or revoked. You

must:

(1) act according to any instructions from the principal, or, where

there are no instructions, in the principal's best interest;

(2) avoid conflicts that would impair your ability to act in the

principal's best interest;

(3) keep the principal's property separate and distinct from any

assets you own or control, unless otherwise permitted by law;

(4) keep a record of all transactions conducted for the principal or

keep all receipts of payments and transactions conducted for the

principal; and

(5) disclose your identity as an agent whenever you act for the

principal by writing or printing the principal's name and signing your

own name as "agent" in either of the following manners: (Principal's

Name) by (Your Signature) as Agent, or (your signature) as Agent for

(Principal's Name).

You may not use the principal's assets to benefit yourself or anyone

else or make gifts to yourself or anyone else unless the principal has

specifically granted you that authority in the modifications section of

this document or a Non-Statutory Power of Attorney. If you have that

authority, you must act according to any instructions of the principal

or, where there are no such instructions, in the principal's best

interest. You may resign by giving written notice to the principal and

to any co-agent, successor agent, monitor if one has been named in this

document, or the principal's guardian if one has been appointed. If

there is anything about this document or your responsibilities that you

do not understand, you should seek legal advice.

Liability of agent:

The meaning of the authority given to you is defined in New York's

General Obligations Law, Article 5, Title 15. If it is found that you

have violated the law or acted outside the authority granted to you in

the Power of Attorney, you may be liable under the law for your

violation.

(p) AGENT'S SIGNATURE AND ACKNOWLEDGMENT OF APPOINTMENT:

It is not required that the principal and the agent(s) sign at the

same time, nor that multiple agents sign at the same time.

I/we, ___________________________________________, have read the

foregoing Power of Attorney. I am/we are the person(s) identified

therein as agent(s) for the principal named therein.

I/we acknowledge my/our legal responsibilities.

In Witness Whereof I have hereunto signed my name on ________________

20_____.

Agent(s) sign(s) here:==>__________________________________________

(acknowledgment(s))

(q) SUCCESSOR AGENT'S SIGNATURE AND ACKNOWLEDGMENT OF APPOINTMENT:

It is not required that the principal and the SUCCESSOR agent(s), if

any, sign at the same time, nor that multiple SUCCESSOR agents sign at

the same time. Furthermore, successor agents can not use this power of

attorney unless the agent(s) designated above is/are unable or unwilling

to serve.

I/we, ___________________________________________, have read the

foregoing Power of Attorney. I am/we are the person(s) identified

therein as SUCCESSOR agent(s) for the principal named therein.

In Witness Whereof I have hereunto signed my name on ________________

20_____.

Successor Agent(s) sign(s) here:==>______________________________________

(acknowledgment(s))"