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NEBRASKA STATUTORY SHORT FORM POWER OF ATTORNEY
The following statutory short form, when reproduced and used in the identical indicated words or in substantially the same or more similar than dissimilar formulation of words by means of printing, typing, writing, or other method of reproduction and use or when appropriately adapted to particular circumstances, shall be and constitute a statutory short form power of attorney and, when completed by adoption by check or other clear mark of each included provision desired and permitted to be adopted and made operative, by deletion by line or other clear obliteration of each included provision desired and permitted to be deleted and made inoperative, by inclusion by printing, typing, writing, or other clear presentation of each provision not included but desired and permitted to be included and made operative, and by insertion by printing, typing, writing, or other clear presentation of all additional data and information required to be included and when effectuated by execution by or for the principal, by acknowledgment by or for the principal, and by delivery by or at the express direction of the principal to and acceptance by the agent of at least one so completed, executed, and acknowledged form, shall create and establish an agency relationship under a power of attorney in accordance with the Nebraska Short Form Act.
POWER OF ATTORNEY
____________________________________________________ [full legal name], a domiciliary of _______________ County, Nebraska, Principal, desiring and intending to establish a Power of Attorney operative under the Nebraska Short Form Act, does hereby appoint, constitute, and designate ____________________________________________________ [full legal name], a domiciliary of or with an office in ______________________ County, Nebraska, and ____________________________________________________ [full legal name], a domiciliary of or with an office in _________________ County, Nebraska, Agent, the lawful and true Agent and attorney in fact for Principal; and Principal does hereby further provide and stipulate in connection therewith as follows:
1. This Power of Attorney is, as marked, a
( ) Durable Power of Attorney and a
( ) Contingent Durable Power of Attorney, upon the contingency of,
( ) Incompetence of Principal, or
( ) Other Contingency: _____________________________, or
( ) Present Durable Power of Attorney
( ) Nondurable Power of Attorney.
2. By this Power of Attorney, Principal confers upon and grants to Agent plenary power, plenary power subject to limitations, or all and each of the listed general powers as individually marked:
( ) Plenary Power; or
( ) Plenary Power Subject to Limitations, exclusive of General Powers for Domestic and Personal
Concerns and for Fiduciary Relationships and
( ) No Other Restrictions, or
( ) Other Restrictions: _____________________________; or
( ) General Power for Bank and Financial Transactions.
( ) General Power for Business Interests.
( ) General Power for Chattels and Goods.
( ) General Power for Disputes and Litigation.
( ) General Power for Domestic and Personal Concerns.
( ) General Power for Fiduciary Relationships.
( ) General Power for Governmental and Other Benefits.
( ) General Power for Insurance Coverages and Policies.
( ) General Power for Proprietary Interests and Materials.
( ) General Power for Real Estate.
( ) General Power for Securities.
( ) General Power for Records, Reports, and Statements.
3. By this Power of Attorney, Principal makes the following additional provision or provisions:
4. This Power of Attorney revokes and supersedes all prior executed instruments of like import and remains operative until revoked.
EXECUTED AT ____________________ [city], _____________ County, Nebraska, on _____________________ , 20______ .
STATE OF NEBRASKA
COUNTY OF _________________
The foregoing instrument was acknowledged before me on ___________________, 20_____, by the Principal ____________________.
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