Georgia Statutory Form Power of Attorney

STATUTORY FORM POWER OF ATTORNEY

O.C.G.A. § 10-6B-70

State of Georgia

County of _____________________________________________

IMPORTANT INFORMATION

This power of attorney authorizes another person (your agent) to make decisions concerning your property for you (the principal). Your agent will be able to make decisions and act with respect to your property (including your money) whether or not you are able to act for yourself. The meaning of authority over subjects listed on this form is explained in O.C.G.A. Chapter 6B of Title 10.

This power of attorney does not authorize the agent to make health care decisions for you.

You should select someone you trust to serve as your agent. Unless you specify otherwise, generally the agent's authority will continue until you die or revoke the power of attorney or the agent resigns, is unable to act for you or is removed by a court. If you revoke the power of attorney, you must communicate your revocation by notice to the agent in writing by certified mail and file such notice with the clerk of superior court in your county of domicile (where you live).

Your agent is not entitled to any compensation unless you state otherwise in the Special Instructions. Your agent shall be entitled to reimbursement of reasonable expenses incurred in performing the acts required by you in your power of attorney.

This form provides for designation of one agent. If you wish to name more than one agent, you may name a successor agent or name a coagent in the Special Instructions. Coagents will not be required to act together unless you include that requirement in the Special Instructions.

If your agent is unable or unwilling to act for you, your power of attorney will end unless you have named a successor agent. You may also name a second successor agent.

This power of attorney shall be durable (it will continue to be effective even if you become incapacitated) unless you state otherwise in the Special Instructions.

This power of attorney becomes effective immediately unless you state otherwise in the Special Instructions.

If you have questions about the power of attorney or the authority you are granting to your agent, you should seek advice from an attorney before signing this form.

DESIGNATION OF AGENT

I, __________________________________________________

Name of principal

name the following person as my agent:

Name of agent: ____________________________________________

Agent's address: ____________________________________________

Agent's telephone number: ____________________________________________

Agent's e-mail address: ____________________________________________

DESIGNATION OF SUCCESSOR AGENT(S) (OPTIONAL)

If my agent is unable or unwilling to act for me, I name as my successor agent:

Name of successor agent: _______________________________________

Successor agent's address: _______________________________________

Successor agent's telephone number: _______________________________________

Successor agent's e-mail address: _______________________________________

If my successor agent is unable or unwilling to act for me, I name as my second successor agent:

Name of second successor agent: ________________________________

Second successor agent's address: ________________________________

Second successor agent's telephone number: ________________________________

Second successor agent's e-mail address: ________________________________

GRANT OF GENERAL AUTHORITY

I grant my agent and any successor agent general authority to act for me with respect to the following subjects as defined in O.C.G.A. Chapter 6B of Title 10:

(INITIAL each subject you want to include in the agent's general authority. If you wish to grant general authority over all of the subjects you may initial "All preceding subjects" instead of initialing each subject.)

(___) Real property

(___) Tangible personal property

(___) Stocks and bonds

(___) Commodities and options

(___) Banks and other financial institutions

(___) Operation of entity or business

(___) Insurance and annuities

(___) Estates, trusts, and other beneficial interests

(___) Claims and litigation

(___) Personal and family maintenance

(___) Benefits from governmental programs or civil or military service

(___) Retirement plans

(___) Taxes

(___) All preceding subjects

GRANT OF SPECIFIC AUTHORITY (OPTIONAL)

My agent SHALL NOT do any of the following specific acts for me UNLESS I have INITIALED the specific authority listed below:

(CAUTION: Granting any of the following will give your agent the authority to take actions that could significantly reduce your property or change how your property is distributed at your death. INITIAL ONLY the specific authority that you do WANT to give your agent. DO NOT INITIAL Any Authority You Do Not Want Your Agent to Have. You should give your agent specific instructions in the Special Instructions when you authorize your agent to make gifts.)

(___) Create, amend, revoke, or terminate an inter vivos trust

(___) Make a gift, subject to the limitations of O.C.G.A. § 10-6B-56 and any Special Instructions in this power of attorney Create or change rights of survivorship

(___) Create or change a beneficiary designation

(___) Authorize another person to exercise the authority granted under this power of attorney

(___) Waive the principal's right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan Access the content of electronic communications

(___) Exercise fiduciary powers that the principal has authority to delegate

(___) Disclaim or refuse an interest in property, including a power of appointment

AUTHORITY TO ACT AS HIPAA REPRESENTATIVE (OPTIONAL)

By initialing this statement, I hereby authorize my agent to act as my personal representative pursuant to the Health Insurance Portability and Accountability Act (HIPAA), Sections 1171 through 1179 of the Social Security Act, 42 U.S.C. Section 1320d, in effect on February 1, 2017, and applicable regulations in effect on February 1, 2017, to obtain access to my health care information and communicate with my health care provider, unless this authorization conflicts with any other appointment of such representative.

LIMITATION ON AGENT'S AUTHORITY

An agent that is not my ancestor, spouse, or descendant SHALL NOT use my property to benefit the agent or a person to whom the agent owes an obligation of support unless I have included that authority in the Special Instructions.

SPECIAL INSTRUCTIONS (OPTIONAL)

You may give special instructions on the following lines (you may add lines or place your special instructions in a separate document and attach it to the power of attorney):

________________________________________________________________________

________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

EFFECTIVE DATE OF POWER OF ATTORNEY

This power of attorney is effective immediately unless I have stated otherwise in the Special Instructions.

NOMINATION OF CONSERVATOR (OPTIONAL)

If it becomes necessary for a court to appoint a conservator of my estate, I nominate the following person(s) for appointment:

Name of nominee for conservator of my estate: __________________________________

Nominee's address: __________________________________

Nominee's telephone number: __________________________________

Nominee's e-mail address: __________________________________

RELIANCE ON THIS POWER OF ATTORNEY

This power of attorney revokes any other financial power of attorney previously executed by me unless I have stated otherwise in the Special Instructions.

Any person, including my agent, may rely upon the validity of this power of attorney or a copy of it unless that person has actual knowledge it has terminated or is invalid.

SIGNATURES AND ACKNOWLEDGMENT

Principal's signature: _____________________________________________ Date: _________________________

Principal's name printed: ___________________________________________

Principal's address: ___________________________________________

___________________________________________

Principal's telephone number: ___________________________________________

Principal's e-mail address: ___________________________________________

WITNESS 1

This document was signed in my presence on this the _____ day of ________________, ________,

by ________________________________________________

Name of principal

Witness's signature: ______________________________________________

Witness's name printed: __________________________________________

Witness's address: _________________________________________________

________________________________________________________________________

Witness's telephone number: _______________________________________

Witness's e-mail address: __________________________________________

WITNESS 2 (OPTIONAL)

This document was signed in my presence on this the _____ day of ________________, ________,

by ________________________________________________

Name of principal

Witness's signature: ______________________________________________

Witness's name printed: __________________________________________

Witness's address: _________________________________________________

________________________________________________________________________

Witness's telephone number: _______________________________________

Witness's e-mail address: __________________________________________

NOTARY ACKNOWLEDGMENT

State of Georgia

County of __________________________________________

This document was signed in my presence on this the _____ day of _______________, ________, by ____________________________, principal, and witness(es)

__________________________________________________

Second witness optional

Signature of notary: ____________________________________________

My commission expires: ______________________________________

This document prepared by: ______________________________________

IMPORTANT INFORMATION FOR AGENT

Agent's Duties

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 upon you legal duties that continue until you resign or the power of attorney is terminated or revoked.

You must:

(1) Do what you know the principal reasonably expects you to do with the principal's property or, if you do not know the principal's expectations, act in the principal's best interest;

(2) Act in good faith;

(3) Do nothing beyond the authority granted in this power of attorney;

(4) Disclose your identity as an agent whenever you act for the principal by writing or printing the name of the principal and signing your own name as "agent" in the following manner:

______________________________ by _________________________ as Agent. (Principal's printed name) (Agent's signature)

Unless the Special Instructions in this power of attorney state otherwise, you must also:

(1) Act loyally for the principal's benefit;

(2) Avoid conflicts that would impair your ability to act in the principal's best interest;

(3) Act with care, competence, and diligence;

(4) Keep a record of all receipts, disbursements, and transactions made on behalf of the principal;

(5) Cooperate with any person that has authority to make health care decisions for the principal to do what you know the principal reasonably expects or, if you do not know the principal's expectations, to act in the principal's best interest;

(6) Attempt to preserve the principal's estate plan if you know the plan and preserving the plan is consistent with the principal's best interest;

Termination of Agent's Authority

You must stop acting on behalf of the principal if you learn of any event that terminates this power of attorney or your authority under this power of attorney. Events that terminate a power of attorney or your authority to act under a power of attorney include:

(1) Death of the principal;

(2) The principal's revocation of your authority or the power of attorney so as long as the revocation of the power of attorney is communicated to you in writing by certified mail and provided that such notice is filed with the clerk of superior court in the county of domicile of the principal;

(3) The occurrence of a termination event stated in the power of attorney;

(4) The purpose of the power of attorney is fully accomplished;

(5) If you are married to the principal, a legal action is filed with a court to end your marriage, or for your legal separation, unless the Special Instructions in this power of attorney state that such an action will not terminate your authority;

Liability of Agent

The meaning of the authority granted to you is defined in O.C.G.A. Chapter 6B of Title 10. If you violate O.C.G.A. Chapter 6B of Title 10 or act outside the authority granted, you may be liable for any damages caused by your violation.

If there is anything about this document or your duties that you do not understand, you should seek legal advice.

- Optional Agent's Certification -

AGENT'S CERTIFICATION AS TO THE VALIDITY OF POWER OF ATTORNEY AND AGENT'S AUTHORITY

O.C.G.A. § 10-6B-70

State of Georgia

County of __________________________________________

I, ______________________________________ (name of agent), certify under penalty of perjury that ___________________________________ (name of principal) granted me authority as an agent or successor agent in a power of attorney dated __________________.

I further certify that to my knowledge:

(1) The principal is alive and has not revoked the power of attorney or my authority to act under the power of attorney and the power of attorney and my authority to act under the power of attorney have not terminated;

(2) If the power of attorney was drafted to become effective upon the happening of an event or contingency, the event or contingency has occurred;

(3) If I were named as a successor agent, the prior agent is no longer able or willing to serve;

(4) __________________________________________________________________

________________________________________________________________________ ________________________________________________________________________

________________________________________________________________________ Insert other relevant statements

SIGNATURE AND ACKNOWLEDGMENT

Agent's signature: ________________________________________________ Date: ____________________________

Agent's name printed: ____________________________________________

Agent's address: ____________________________________________

____________________________________________

Agent's telephone number: ____________________________________________

Agent's e-mail address: ____________________________________________

This document was signed in my presence on the ______ day of ________________, ________, by __________________________________.

Signature of notary: _____________________________________________

My commission expires: _______________________________________

This document prepared by: ______________________________________