New Hampshire General Durable Power of Attorney for Property & Finances (Upon Disability)

New Hampshire General Durable Power of Attorney
for Property & Finances (Upon Disability)

PACKET GUIDE — REMOVE THIS GUIDE BEFORE SIGNING OR RECORDING. THE STATUTORY FORM BEGINS ON THE PAGE TITLED "NEW HAMPSHIRE STATUTORY POWER OF ATTORNEY."

New Hampshire General Durable Power of Attorney for Property & Finances — Packet Guide

This packet contains the New Hampshire statutory power of attorney form (RSA 564-E:301), which becomes effective only upon a written determination of your incapacity (springing), plus spare Agent Acknowledgment pages for successor agents, the optional Agent's Certification form (RSA 564-E:302) with a spare copy, an optional written-determination page for the person who determines incapacity, and an optional recording cover page.

https://gc.nh.gov/rsa/html/LVI/564-E/564-E-mrg.htm

What this document is

This packet builds on New Hampshire's statutory power of attorney form under the Uniform Power of Attorney Act (RSA 564-E, effective January 1, 2018). A document "substantially" in the statutory form creates a power of attorney with the meaning and effect the act prescribes (RSA 564-E:301). This packet reproduces the statutory form and adds clearly labeled optional pages, each described below. Read this guide, then remove it before signing and before recording: it is not part of the power of attorney.

The power is "durable": your agent's authority continues even if you later become incapacitated, unless the instrument expressly provides otherwise (RSA 564-E:104). It covers property and finances only — it does not authorize health-care decisions. New Hampshire health-care decisions use an advance directive under RSA 137-J, which is a separate document.

How to sign (RSA 564-E:105)

Sign the power of attorney — and sign the disclosure statement at the top — in ink. New Hampshire does not allow these signatures to be made by electronic signature. If you are physically unable to sign, another person may sign your name in your conscious presence and at your express direction. Your signature must be acknowledged before a notary public or another individual authorized to take acknowledgments. No witnesses are required. A New Hampshire notary may perform the acknowledgment for a remotely located signer, but your signature itself must still be a tangible ink mark — do not sign this document through an e-signature platform (RSA 456-B:6-a; RSA 564-E:105(a)). Keep the signed disclosure statement affixed to the power of attorney — New Hampshire law requires it, and the combination of the disclosure, the agent's signed acknowledgment, and an express gift grant is what gives a later gift the benefit of the legal presumption described below (RSA 564-E:116(g)).

Your agent cannot act until the agent signs the acknowledgment (RSA 564-E:113)

The person you name as agent has no authority to act until he or she signs the Agent Acknowledgment at the end of the statutory form (in ink, not by electronic signature) and affixes it to the power of attorney. The agent may sign it at any time before first acting — it does not have to be signed when you sign. Give the agent the document early so this step is done before the agent needs to act. The same rule applies to every successor agent: spare Agent Acknowledgment pages follow the form so each successor can sign and affix one when the time comes.

When this power takes effect (springing variant)

This variant takes effect only upon a written determination that you are incapacitated within the meaning of RSA 564-E:102(12). The pre-printed Special Instruction in Paragraph 6 makes that election and lets you name the person who makes the determination (RSA 564-E:109(b)). If you do not name anyone, or your designee cannot or will not act, the determination is made by a physician, or — if you are missing, detained, or outside the United States — by a judge or an appropriate governmental official (RSA 564-E:109(c)). The person you authorize to make the determination may act as your personal representative under HIPAA to obtain the health information needed to decide (RSA 564-E:109(d)). You may edit or delete the pre-printed election before signing; if you delete it entirely, the power is effective when executed (RSA 564-E:109(a)). Once the determination is made, the power remains in effect even if you later recover capacity — "Upon Disability" controls when the power starts; it does not switch off again — until you revoke it or the law ends it. If you want the power to pause during any period of recovered capacity, you must write that into the Special Instructions yourself. The optional written-determination page at the end of this packet gives the person who determines incapacity a ready-made record to sign; keep the signed original with this power of attorney — the Agent's Certification form refers to it.

Choosing your agent's powers

In Paragraph 4, initial choice A to give your agent general authority over all matters, or choice B and then initial only the subjects you want to include — do not initial both A and B. Paragraph 5 lists actions New Hampshire calls "specific authority": your agent may not do any of them unless you initial the line. Several carry their own sub-elections that let your agent act for his or her own benefit — initial those only after careful thought, because they let your agent change who receives your property. New Hampshire has no fixed dollar limit on agent gifts; instead, a gift must be consistent with your objectives or best interest under the seven factors of RSA 564-E:217, and a gift that would leave you without sufficient assets for your care requires a separate express election (or advance court approval). If a court is petitioned to review a gift, the gift is presumed lawful when this power includes the signed disclosure statement, the agent's signed acknowledgment, and an express gift grant; without them, the agent may still prove the gift was authorized — and if the proposed gift would benefit your agent, the court must appoint a guardian ad litem to represent you in that review (RSA 564-E:116(g)). Initialing the gift line does not remove the seven-factor standard. The self-dealing bar on non-gift acts does not apply to an agent who is your ancestor, spouse, or descendant (RSA 564-E:201(b)(2)) — but a gift to the agent personally always requires the express self-gift election. Initialing "Digital Assets" lets the agent access and manage your accounts; reading the content of your email and messages requires the separate specific-authority line (RSA 554-A:9). New Hampshire's form also adds an intellectual-property subject — copyrights, royalty contracts, and trademarks. The "Exercise the fiduciary power(s)" line grants nothing unless the powers are described in the Special Instructions: if you initial it, name the trust or role and the powers in Paragraph 6.

Rules your agent must follow

Your agent is a fiduciary: after accepting, the agent must act in accordance with your reasonable expectations, in your best interest, in good faith, and only within the authority granted (RSA 564-E:114). The agent must keep records of all transactions and must answer a written request for an accounting within 60 days (7 days if the decision affects health care). Unless your instrument says otherwise, your agent is entitled to reimbursement of expenses and to reasonable compensation (RSA 564-E:112) — a sample no-compensation sentence is in the Special Instructions suggestions below. If a court ever appoints a conservator or guardian of your estate, this power of attorney is not terminated: your agent remains authorized unless the court orders otherwise, becomes accountable to the court-appointed fiduciary, and that fiduciary may revoke or suspend the power as you could (RSA 564-E:108(b)).

Co-agents, successors, divorce, and revocation

You may name two or more co-agents, but unless you provide otherwise they must act jointly (RSA 564-E:111(a)) — a sample sentence allowing them to act severally is below. A successor agent steps in only when every predecessor is unable or unwilling to serve. If your agent is your spouse, the filing of a petition for divorce, annulment, separation, or nullity ends the spouse-agent's authority unless your instrument provides otherwise (RSA 564-E:110(b)(3)) — a sample continuation sentence is below. You may revoke this power of attorney at any time while you are of sound mind; telling your agent and any institutions in writing is the reliable practice. Signing a new power of attorney does not revoke an earlier one unless it says so (RSA 564-E:110(f)) — Paragraph 3 of the form makes that election.

If a bank or other institution hesitates

A person presented with your acknowledged power of attorney must accept it or timely request a certification, translation, or opinion of counsel — within 7 business days — and must accept it within 5 business days after receiving what it requested. It may not demand a different form of power of attorney. This chapter does not override other law that applies to financial institutions — if such a law conflicts, it controls (RSA 564-E:122) — but the no-other-form rule still stands. A refusal that violates these rules can be ordered accepted by a court, with attorney's fees (RSA 564-E:119 and 564-E:120). The Agent's Certification in this packet (RSA 564-E:302) is the form your agent uses to answer a certification request. A photocopy or electronic copy of the signed original has the same effect as the original (RSA 564-E:106(d)).

Special Instructions suggestions (optional)

Paragraph 6 is yours to customize. Commonly used sentences: "My co-agents may act severally." — "My agent shall serve without compensation but remains entitled to reimbursement of reasonable expenses." — "If my agent is my spouse, the filing of an action for divorce, annulment, separation, or nullity shall not terminate my agent's authority." — "My agent may not make gifts of my property." — "If guardianship or conservatorship proceedings are ever begun for me, I nominate [name] to serve as my guardian or conservator." (the court must follow your most recent nomination absent good cause or disqualification — RSA 564-E:108(a)). Leave the section blank if none apply; you may attach additional signed pages.

Recording (real estate only)

You do not have to record this power of attorney for it to be valid. If your agent will sign a deed or other real-estate document, the power of attorney must be signed and acknowledged — as this one is — and it may then be recorded with the registry of deeds like a deed (RSA 477:9). Registries require the document to recite the grantee's mailing address, to name every municipality where the property lies in the first sentence of the first description paragraph, and to print or type each signer's name beneath the signature (RSA 478:4-a). The optional cover page at the end of this packet collects that information for the registry; attach it as the first page only if you record. If a deed will convey or encumber your homestead, New Hampshire requires the owner and the owner's spouse to sign the deed (RSA 480:5-a) — your agent's signature on the deed cannot supply a non-owner spouse's joinder; a non-owner spouse signs personally or through his or her own power of attorney.

Not health-care authority

This document does not authorize anyone to make medical or other health-care decisions for you. New Hampshire health-care and end-of-life decisions use an advance directive under RSA 137-J (a separate document). The revocation election in Paragraph 3 never revokes a health-care power of attorney.

This packet is a form, not legal advice. Because powers of attorney can change who controls your money and property, consider reviewing your completed document with a licensed New Hampshire attorney before you sign.

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NEW HAMPSHIRE

STATUTORY POWER OF ATTORNEY

(General Durable Power of Attorney for Property & Finances — Effective Upon Disability)

[Packet subtitle — not part of the statutory form]

INFORMATION CONCERNING THE POWER OF ATTORNEY

THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT YOU SHOULD KNOW THESE IMPORTANT FACTS:

Notice to the Principal: As the "Principal," you are using this Power of Attorney to grant power to another person (called the "Agent") to make decisions, including, but not limited to, decisions concerning your money, property, or both, and to use your money, property, or both on your behalf. If this Power of Attorney does not limit the powers that you give to your Agent, your Agent will have broad and sweeping powers to sell or otherwise dispose of your property, and to spend your money without advance notice to you or approval by you. Unless you have expressly provided otherwise in this Power of Attorney, your Agent will have these powers before you become incapacitated, and unless you have expressly provided otherwise in this Power of Attorney, your Agent will continue to have these powers after you become incapacitated. You have the right to retain this Power of Attorney and to release it later or to request that another person retain this Power of Attorney on your behalf and release it only if one or more conditions specified in advance by you are satisfied. You have the right to revoke or take back this Power of Attorney at any time, so long as you are of sound mind. If there is anything about this Power of Attorney that you do not understand, you should seek professional advice.

1. DESIGNATION OF AGENT

I,

_____________________________________________________

(Name of Principal)

of

_____________________________________________________

(Address of Principal)

name the following person as my agent:

Name of Agent: ___________________________________________

Agent's Address: _________________________________________

2. DESIGNATION OF SUCCESSOR AGENT(S) (OPTIONAL)

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

Name of Successor Agent: _________________________________

Successor Agent's Address: _______________________________

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

Name of Second Successor Agent: __________________________

Second Successor Agent's Address: ________________________

3. REVOCATION OF EXISTING POWERS OF ATTORNEY

(Initial the following statement if it is your choice.)

__________ This Power of Attorney revokes all existing powers of attorney, except for powers of attorney relating to health care, previously executed by me.

4. GRANT OF GENERAL AUTHORITY

(Initial beside your choice of A or B, but not both.)

__________ A. I grant my agent general authority to act for me in all matters, including, without limitation, all of the subjects enumerated in B below.

__________ B. I grant my agent general authority over the following subjects:

(Initial each subject you want to include in the agent's general authority.)

__________ Real Property as defined in RSA 564-E:204

__________ Tangible Personal Property as defined in RSA 564-E:205

__________ Stocks and Bonds as defined in RSA 564-E:206

__________ Commodities and Options as defined in RSA 564-E:207

__________ Banks and Other Financial Institutions as defined in RSA 564-E:208

__________ Operation of Entity or Business as defined in RSA 564-E:209

__________ Insurance and Annuities as defined in RSA 564-E:210

__________ Estates, Trusts and Other Beneficial Interests as defined in RSA 564-E:211

__________ Claims and Litigation as defined in RSA 564-E:212

__________ Personal and Family Maintenance as defined in RSA 564-E:213

__________ Benefits from Governmental Programs or Civil or Military Service as defined in RSA 564-E:214

__________ Retirement Plans as defined in RSA 564-E:215

__________ Taxes as defined in RSA 564-E:216

__________ Digital Assets as defined in RSA 554-A:2(10)

5. GRANT OF SPECIFIC AUTHORITY (OPTIONAL)

(Initial each subject you want to include in the agent's authority. CAUTION: As to some of the following subjects, granting your agent authority 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.)

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

__________ Create, amend, revoke, or terminate an inter vivos trust

(If you have granted your agent the authority to create, amend, revoke, or terminate an inter vivos trust, then initial the following statement if it is your choice.)

__________ My agent may create, amend, revoke, or terminate an inter vivos trust to benefit himself or herself or any individual to whom my agent owes a legal obligation of support.

__________ Make a gift, subject to the limitations of RSA 564-E:217

(If you have granted your agent the authority to make a gift, then as to each of the following statements, initial beside it if it is your choice.)

__________ My agent may make a gift, even if it will leave me without sufficient assets or income to provide for my care without relying on Medicaid, other public assistance or charity.

__________ My agent may make a gift to himself or herself and to any individual to whom my agent owes a legal obligation of support.

__________ Create or change rights of survivorship

(If you have granted your agent the authority to create or change rights of survivorship, then initial the following statement if it is your choice.)

__________ My agent may create or change rights of survivorship to benefit himself or herself or any individual to whom my agent owes a legal obligation of support.

__________ Create or change a beneficiary designation

(If you have granted your agent the authority to create or change a beneficiary designation, then initial the following statement if it is your choice.)

__________ My agent may create or change a beneficiary designation to benefit himself or herself or any individual to whom my agent owes a legal obligation of support.

__________ Reject, renounce, disclaim, release, or consent to a reduction in or modification of my share in, or a payment to me from, an estate, trust, or other beneficial interest, to benefit my agent or any individual to whom my agent owes a legal obligation of support

__________ Delegate authority granted under this Power of Attorney to another person

__________ Waive my right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan

(If you have granted your agent the authority to waive your right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan, then initial the following statement if it is your choice.)

__________ My agent may waive my right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan, to benefit himself or herself or any individual to whom my agent owes a legal obligation of support.

__________ Exercise the fiduciary power(s) that I have the authority to delegate as specified in the "Special Instructions" in Paragraph 6 of this Power of Attorney

__________ Exercise authority over the content of electronic communication sent or received by me pursuant to RSA 554-A:9

__________ Exercise authority with respect to intellectual property, including, without limitation, copyrights, contracts for payment of royalties, and trademarks

6. SPECIAL INSTRUCTIONS (OPTIONAL)

(Here you may include special instructions. You may leave this Paragraph blank. You may attach additional pages as necessary.)

PRE-PRINTED ELECTION — you may edit or delete it before signing; if you delete it entirely, this Power of Attorney is effective when executed.

EFFECTIVENESS UPON INCAPACITY. This Power of Attorney shall become effective only upon a written determination that I am incapacitated within the meaning of RSA 564-E:102(12). The determination shall be made in a writing or other record, signed and dated.

I authorize the following person(s) to make that determination (RSA 564-E:109(b)):

_____________________________________________________

Name(s) of Person(s) designated to make the determination (optional)

Address and telephone of designated person(s): _____________________

If I have not designated a person above, or the person I designated is unable or unwilling to act, the determination shall be made as provided by RSA 564-E:109(c): by a physician who determines that I am incapacitated within the meaning of RSA 564-E:102(12)(A), or — if I am missing, detained (including incarcerated), or outside the United States and unable to return — by a judge or an appropriate governmental official who determines that I am incapacitated within the meaning of RSA 564-E:102(12)(B).

A person I have authorized above to determine that I am incapacitated may act as my personal representative under the Health Insurance Portability and Accountability Act (42 U.S.C. section 1320d and applicable regulations) to obtain access to my health-care information and to communicate with my health-care provider (RSA 564-E:109(d)).

Once this Power of Attorney becomes effective, it remains exercisable during any later period in which I have capacity, unless and until it is revoked or terminated as provided by law.

_____________________________________________________

_____________________________________________________

_____________________________________________________

7. EFFECTIVE DATE AND AUTHORITY OF AGENT

This Power of Attorney is effective immediately unless I have stated otherwise in the Special Instructions in Paragraph 6 of this Power of Attorney. An agent (including successor agent) named in this Power of Attorney will have no authority to act as my agent until he or she has signed and affixed to this Power of Attorney an acknowledgment that is substantially the same as the Acknowledgment at the end of this Power of Attorney.

8. GOVERNING LAW

This Power of Attorney shall be governed by the laws of the State of New Hampshire.

9. RELIANCE ON THIS POWER OF ATTORNEY

Any person, including my agent, may rely upon this Power of Attorney if it is acknowledged before a notary public or other individual authorized to take acknowledgments (or a copy of the acknowledged Power of Attorney), unless that person knows it is void, invalid, or terminated.

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SIGNATURE AND ACKNOWLEDGMENT

(You must date and sign this Power of Attorney. If you are physically unable to sign, it may be signed by someone else writing your name, in your presence and at your express direction. This Power of Attorney must be acknowledged before a notary public or other individual authorized by law to take acknowledgments.)

_____________________________________________________

Principal's Signature

_____________________________________________________

Principal's Printed Name

_____________________________________________________

Principal's Address

_____________________________________________________

Date

STATE OF NEW HAMPSHIRE

COUNTY OF _________________________

The foregoing Power of Attorney was acknowledged before me on _________________________ , by

_____________________________________________________

known to me or satisfactorily proven to be the person named herein

_____________________________________________________

Signature of Notarial Officer

Title (and Rank): ____________________________________

My commission expires: _______________________________

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AGENT ACKNOWLEDGMENT

Notice to Agent: You will have no authority to act as agent under this Power of Attorney until you sign and affix this acknowledgment to the Power of Attorney.

I, ______________________________ , have read the attached power of attorney and am the person identified as the agent for the principal. I hereby acknowledge that when I act as agent I am given power under the power of attorney to make decisions about money, property, or both belonging to the principal, and to spend the principal's money, property, or both on the principal's behalf, in accordance with the terms of the power of attorney. When acting as agent, I have duties (called "fiduciary duties") to act in accordance with the principal's reasonable expectations to the extent actually known by me and, otherwise, in the principal's best interest, to act in good faith, and to act only within the scope of authority granted in the power of attorney, as well as other duties imposed by law to the extent not provided otherwise in the power of attorney. As an agent, I am not entitled to use the money or property for my own benefit or to make gifts to myself or others unless the power of attorney specifically gives me the authority to do so. As an agent, my authority under the power of attorney will end when the principal dies and I will not have authority to manage or dispose of any property or administer the estate of the principal. If I violate a fiduciary duty under the power of attorney, I may be liable for damages and may be subject to criminal prosecution. If there is anything about this power of attorney, or my duties under it, that I do not understand, I understand that I should seek professional advice.

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OPTIONAL SPARE — for Successor Agent 1: a successor agent has no authority to act until he or she signs and affixes an acknowledgment substantially in this form (RSA 564-E:113(a)); sign in ink, not by electronic signature

AGENT ACKNOWLEDGMENT — SUCCESSOR AGENT 1

Notice to Agent: You will have no authority to act as agent under this Power of Attorney until you sign and affix this acknowledgment to the Power of Attorney.

I, ______________________________ , have read the attached power of attorney and am the person identified as a successor agent for the principal. I hereby acknowledge that when I act as agent I am given power under the power of attorney to make decisions about money, property, or both belonging to the principal, and to spend the principal's money, property, or both on the principal's behalf, in accordance with the terms of the power of attorney. When acting as agent, I have duties (called "fiduciary duties") to act in accordance with the principal's reasonable expectations to the extent actually known by me and, otherwise, in the principal's best interest, to act in good faith, and to act only within the scope of authority granted in the power of attorney, as well as other duties imposed by law to the extent not provided otherwise in the power of attorney. As an agent, I am not entitled to use the money or property for my own benefit or to make gifts to myself or others unless the power of attorney specifically gives me the authority to do so. As an agent, my authority under the power of attorney will end when the principal dies and I will not have authority to manage or dispose of any property or administer the estate of the principal. If I violate a fiduciary duty under the power of attorney, I may be liable for damages and may be subject to criminal prosecution. If there is anything about this power of attorney, or my duties under it, that I do not understand, I understand that I should seek professional advice.

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OPTIONAL SPARE — for Successor Agent 2: a successor agent has no authority to act until he or she signs and affixes an acknowledgment substantially in this form (RSA 564-E:113(a)); sign in ink, not by electronic signature

AGENT ACKNOWLEDGMENT — SUCCESSOR AGENT 2

Notice to Agent: You will have no authority to act as agent under this Power of Attorney until you sign and affix this acknowledgment to the Power of Attorney.

I, ______________________________ , have read the attached power of attorney and am the person identified as a successor agent for the principal. I hereby acknowledge that when I act as agent I am given power under the power of attorney to make decisions about money, property, or both belonging to the principal, and to spend the principal's money, property, or both on the principal's behalf, in accordance with the terms of the power of attorney. When acting as agent, I have duties (called "fiduciary duties") to act in accordance with the principal's reasonable expectations to the extent actually known by me and, otherwise, in the principal's best interest, to act in good faith, and to act only within the scope of authority granted in the power of attorney, as well as other duties imposed by law to the extent not provided otherwise in the power of attorney. As an agent, I am not entitled to use the money or property for my own benefit or to make gifts to myself or others unless the power of attorney specifically gives me the authority to do so. As an agent, my authority under the power of attorney will end when the principal dies and I will not have authority to manage or dispose of any property or administer the estate of the principal. If I violate a fiduciary duty under the power of attorney, I may be liable for damages and may be subject to criminal prosecution. If there is anything about this power of attorney, or my duties under it, that I do not understand, I understand that I should seek professional advice.

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Optional packet addition — the form RSA 564-E:302 provides for your agent to certify the power of attorney when asked

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

STATE OF NEW HAMPSHIRE

COUNTY OF _________________________

I, ______________________________ , certify under penalty of perjury that ______________________________ granted me authority as an 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 was named as a successor agent, the prior agent is no longer able or willing to serve; and

(4) (Insert Other Relevant Statement(s))

_____________________________________________________

_____________________________________________________

SIGNATURE AND ACKNOWLEDGMENT

Agent's Signature: ________________________________________

Date: ________________________________________________

Agent's Name Printed _____________________________________

Agent's Address _________________________________________

Agent's Telephone Number _________________________________

Signed and sworn to (or affirmed) before me on _______________________ , by

_____________________________________________________

known to me or satisfactorily proven to be the person named herein

_____________________________________________________

Signature of Notarial Officer

Title (and Rank): ____________________________________

My commission expires: _______________________________

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SPARE COPY — use the first copy before this one

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

STATE OF NEW HAMPSHIRE

COUNTY OF _________________________

I, ______________________________ , certify under penalty of perjury that ______________________________ granted me authority as an 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 was named as a successor agent, the prior agent is no longer able or willing to serve; and

(4) (Insert Other Relevant Statement(s))

_____________________________________________________

_____________________________________________________

SIGNATURE AND ACKNOWLEDGMENT

Agent's Signature: ________________________________________

Date: ________________________________________________

Agent's Name Printed _____________________________________

Agent's Address _________________________________________

Agent's Telephone Number _________________________________

Signed and sworn to (or affirmed) before me on _______________________ , by

_____________________________________________________

known to me or satisfactorily proven to be the person named herein

_____________________________________________________

Signature of Notarial Officer

Title (and Rank): ____________________________________

My commission expires: _______________________________

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OPTIONAL PACKET ADDITION — not part of the statutory form; give this page to the person who will determine incapacity

WRITTEN DETERMINATION OF INCAPACITY

New Hampshire Statutory Power of Attorney — Effective Upon Disability (RSA 564-E:301)

The attached power of attorney takes effect only upon a written determination that the principal is incapacitated (RSA 564-E:109). This page gives the person making that determination a ready-made record: it is the writing RSA 564-E:109 requires, and it supports item (2) of the Agent's Certification (RSA 564-E:302). Keep the signed original with the signed power of attorney.

I, ______________________________ , am __________________________________ (physician, license, office, or other capacity), and I am the person the principal authorized in the power of attorney to determine that the principal is incapacitated (or I make this determination as provided by RSA 564-E:109(c)). I have determined that ______________________________ , the principal, is incapacitated within the meaning of RSA 564-E:102(12).

This determination is made in a writing signed and dated below.

Signature of person making the determination: _____________________

Date: ________________________________________________

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OPTIONAL COVER PAGE — attach as the first page only if you record this power of attorney with a registry of deeds; it is not part of the legal instrument

RECORDING COVER PAGE

New Hampshire Statutory Power of Attorney (RSA 564-E:301)

A power of attorney to convey real estate must be signed and acknowledged, and may then be recorded as required for a deed (RSA 477:9). The registry of deeds cannot accept an instrument unless it recites the grantee's mailing address, names every municipality where the property lies in the first sentence of the first description paragraph, and prints or types each signer's name beneath the signature (RSA 478:4-a(I)). Registers also set reproduction standards for paper and margins (RSA 478:4-a(II)) — check your county registry's current standards before recording.

Date of document: _____________________________________

Grantor (Principal) — full name: _______________________

Grantee (Agent) — full name: _________________________

Grantee's mailing address: _____________________________

Municipality(ies) where the affected real estate is located (name each one):

_____________________________________________________

Legal description of the property (if this power will be used for a specific parcel — not the street address):

_____________________________________________________

_____________________________________________________

The description above, if any, is recording-index information only and does not limit the authority granted by the power of attorney.

After recording, return to:

_____________________________________________________

Name and address for return of the recorded document