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North Carolina Statutory Short Form of General Power of Attorney

NOTICE

THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD AND SWEEPING. THEY ARE DEFINED IN CHAPTER 32A OF THE NORTH CAROLINA GENERAL STATUTES WHICH EXPRESSLY PERMITS THE USE OF ANY OTHER OR DIFFERENT FORM OF POWER OF ATTORNEY DESIRED BY THE PARTIES CONCERNED.

State of ______________

County of ____________

I ____________________________, appoint __________________ to be my attorney in fact, to act in my name in any way which I could act for myself, with respect to the following matters as each of them is defined in Chapter 32A of the North Carolina General Statutes. (DIRECTIONS: Initial the line opposite any one or more of the subdivisions as to which the principal desires to give the attorney in fact authority.)

______ (1) Real property transactions

______ (2) Personal property transactions

______ (3) Bond, share, stock, securities and commodity transactions

______ (4) Banking transactions

______ (5) Safe deposits

______ (6) Business operating transactions

______ (7) Insurance transactions

______ (8) Estate transactions

______ (9) Personal relationships and affairs

______ (10) Social security and unemployment

______ (11) Benefits from military service

______ (12) Tax matters

______ (13) Employment of agents

______ (14) Gifts to charities, and to individuals other than the attorney in fact

______ (15) Gifts to the named attorney in fact

(If power of substitution and revocation is to be given, add: 'I also give to such person full power to appoint another to act as my attorney in fact and full power to revoke such appointment.')

(If period of power of attorney is to be limited, add: 'This power terminates______________, ________')

(If power of attorney is to be a durable power of attorney under the provision of Article 2 of Chapter 32A and is to continue in effect after the incapacity or mental incompetence of the principal, add: 'This power of attorney shall not be affected by my subsequent incapacity or mental incompetence.')

(If power of attorney is to take effect only after the incapacity or mental incompetence of the principal, add: 'This power of attorney shall become effective after I become incapacitated or mentally incompetent.')

(If power of attorney is to be effective to terminate or direct the administration of a custodial trust created under the Uniform Custodial Trust Act, add: 'In the event of my subsequent incapacity or mental incompetence, the attorney in fact of this power of attorney shall have the power to terminate or to direct the administration of any custodial trust of which I am the beneficiary.')

(If power of attorney is to be effective to determine whether a beneficiary under the Uniform Custodial Trust Act is incapacitated or ceases to be incapacitated, add: 'The attorney in fact of this power of attorney shall have the power to determine whether I am incapacitated or whether my incapacity has ceased for the purposes of any custodial trust of which I am the beneficiary.')

Dated___________, _______.

 	   (Seal)

Signature __________________

STATE OF ____________________ COUNTY OF _______________

On this ______ day of___________, ______, personally appeared before me, the said named ______________________________ to me known and known to me to be the person described in and who executed the foregoing instrument and he (or she) acknowledged that he (or she) executed the same and being duly sworn by me, made oath that the statements in the foregoing instrument are true.

My Commission Expires ______________________.

__________________________ (Signature of Notary Public)

Notary Public (Official Seal)

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