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Florida General Durable Power of Attorney
for Property & Finances (Upon Disability)
FLORIDA GENERAL DURABLE POWER OF ATTORNEY
THE POWERS YOU GRANT BELOW ARE EFFECTIVE
NOTICE: THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD AND SWEEPING. THEY ARE
EXPLAINED IN THE UNIFORM STATUTORY FORM POWER OF ATTORNEY ACT. IF YOU HAVE ANY
QUESTIONS ABOUT THESE POWERS, OBTAIN COMPETENT LEGAL ADVICE. THIS DOCUMENT
DOES NOT AUTHORIZE ANYONE TO MAKE MEDICAL AND OTHER HEALTH-CARE DECISIONS FOR
YOU. YOU MAY REVOKE THIS POWER OF ATTORNEY IF YOU LATER WISH TO DO SO.
Note: If you initial Item A or Item B, which follow, a notarized signature will be required on behalf of the Principal.
_______ (C) Stock and bond transactions. To purchase, sell, exchange, surrender, assign, redeem, vote at any meeting, or otherwise transfer any and all shares of stock, bonds, or other securities in any business, association, corporation, partnership, or other legal entity, whether private or public, now or hereafter belonging to me.
_______ (D) Commodity and option transactions. To buy, sell, exchange, assign, convey, settle and exercise commodities futures contracts and call and put options on stocks and stock indices traded on a regulated options exchange and collect and receipt for all proceeds of any such transactions; establish or continue option accounts for the principal with any securities or futures broker; and, in general, exercise all powers with respect to commodities and options which the principal could if present and under no disability.
THIS POWER OF ATTORNEY SHALL BE CONSTRUED AS A GENERAL DURABLE POWER OF ATTORNEY.
THIS POWER OF ATTORNEY BECOMES EFFECTIVE ONLY UPON MY DISABILITY OR INCAPACITY. I shall be considered disabled or incapacitated for purposes of this power of attorney if a physician certifies in writing at a date later than the date this power of attorney is executed that, based on the physician's medical examination of me, I am mentally incapable of managing my financial affairs. I authorize the physician who examines me for this purpose to disclose my physical or mental condition to another person for purposes of this power of attorney. A third party who accepts this power of attorney is fully protected from any action taken under this power of attorney that is based on the determination made by a physician of my disability or incapacity.
(YOUR AGENT WILL HAVE AUTHORITY TO EMPLOY OTHER PERSONS AS NECESSARY TO
ENABLE THE AGENT TO PROPERLY EXERCISE THE POWERS GRANTED IN THIS FORM, BUT YOUR
AGENT WILL HAVE TO MAKE ALL DISCRETIONARY DECISIONS. IF YOU WANT TO GIVE YOUR
AGENT THE RIGHT TO DELEGATE DISCRETIONARY DECISION-MAKING POWERS TO OTHERS, YOU
SHOULD KEEP THE NEXT SENTENCE, OTHERWISE IT SHOULD BE STRICKEN.)
Choice of Law. THIS POWER OF ATTORNEY WILL BE GOVERNED BY THE LAWS OF THE STATE OF FLORIDA WITHOUT REGARD FOR CONFLICTS OF LAWS PRINCIPLES. IT WAS EXECUTED IN THE STATE OF FLORIDA AND IS INTENDED TO BE VALID IN ALL JURISDICTIONS OF THE UNITED STATES OF AMERICA AND ALL FOREIGN NATIONS.
I am fully informed as to all the contents of this form and understand the
full import of this grant of powers to my Agent.
STATEMENT OF WITNESS
On the date written above, the principal declared to me in my presence that this instrument is his general durable power of attorney and that he or she had willingly signed or directed another to sign for him or her, and that he or she executed it as his or her free and voluntary act for the purposes therein expressed._______________________________________ [Signature of Witness #1]
_______________________________________ [Printed or typed name of Witness #1]
_______________________________________ [Address of Witness #1, Line 1]
_______________________________________ [Address of Witness #1, Line 2]
_______________________________________ [Signature of Witness #2]
_______________________________________ [Printed or typed name of Witness #2]
_______________________________________ [Address of Witness #2, Line 1]
_______________________________________ [Address of Witness #2, Line 2]
ACKNOWLEDGMENT OF AGENT
BY ACCEPTING OR ACTING UNDER THE APPOINTMENT, THE AGENT ASSUMES THE FIDUCIARY AND OTHER LEGAL RESPONSIBILITIES OF AN AGENT.
This document was prepared by the following individual:
AFFIDAVIT OF AGENT (ATTORNEY IN FACT)
STATE OF FLORIDA
Before me, the undersigned authority, personally appeared
1. Affiant is the attorney in fact named in the Florida General Durable Power of Attorney executed by __________________________________ (principal) ("Principal") on _______________ (date).
2. This Florida General Durable Power of Attorney is currently exercisable by Affiant. The principal is domiciled in _____________________________________________ (insert name of state, territory, or foreign country).
3. To the best of the Affiant's knowledge after diligent search and inquiry:
a. The Principal is not deceased; and
b. There has been no revocation, partial or complete termination by adjudication of incapacity or by the occurrence of an event referenced in the durable power of attorney, or suspension by initiation of proceedings to determine incapacity or to appoint a guardian.
4. Affiant agrees not to exercise any powers granted by the Florida General Durable Power of Attorney if Affiant attains knowledge that it has been revoked, partially or completely terminated, suspended, or is no longer valid because of the death or adjudication of incapacity of the Principal.
CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC
Sworn to (or affirmed) and subscribed before me this ______day of _____________ [month], _________ [year] by ______________________________ [name of agent]. The affiant is [choose one:] ____ personally known to me, or ____ produced the following identification: ________________________________.
AFFIDAVIT OF PHYSICIAN
Before me, the undersigned authority, personally appeared ______________________________ ______________________________ (name of physician), (“Affiant”), who swore or affirmed that:
1. Affiant is a physician licensed to practice medicine in ________________________________ (name of state, territory, or foreign country) .
2. Affiant is the primary physician who has responsibility for the treatment and care of _____________________________________________ (principal's name) .
3. To the best of Affiant's knowledge after reasonable inquiry, Affiant believes that the principal lacks the capacity to manage property, including taking those actions necessary to obtain, administer, and dispose of real and personal property, intangible property, business property, benefits, and income.
CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC
Sworn to (or affirmed) and subscribed before me this ______day of _____________ [month], _________ [year] by ______________________________ [name of physician]. The affiant is [choose one:] ____ personally known to me, or ____ produced the following identification: ________________________________.
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