South Carolina General Durable Power of Attorney for Property & Finances (Upon Disability)

South Carolina General Durable Power of Attorney
for Property & Finances (Upon Disability)

SPACE ABOVE THIS LINE RESERVED FOR RECORDER'S USE

SOUTH CAROLINA GENERAL DURABLE POWER OF ATTORNEY

For Property and Finances

(S.C. Code Title 62, Article 8 — South Carolina Uniform Power of Attorney Act)

(Effective Only Upon My Incapacity)

NOTICE — READ THIS BEFORE YOU SIGN

This power of attorney is an important legal document. It gives the person you name as your agent broad powers over your property and financial affairs, which may include the power to sell or otherwise dispose of your real and personal property without advance notice to you or approval by you.

This document was drafted by PublicLegal for use in South Carolina. It is NOT an official state form — South Carolina has adopted the South Carolina Uniform Power of Attorney Act (S.C. Code §§ 62-8-101 et seq.) but does not prescribe a statutory power of attorney form. This document is drafted to comply with that Act. Under S.C. Code § 62-8-104, a power of attorney is durable by default: it is not terminated by your later incapacity unless the document says otherwise. This document is intended to be durable.

This DURABLE power of attorney takes effect ONLY upon your incapacity, determined in writing as provided in Article II. Until that written determination is made, your agent has no authority over your property or financial affairs except the limited records-access authority described in Article II.

SOUTH CAROLINA RECORDING REQUIREMENT — READ CAREFULLY. Under S.C. Code § 62-8-109(c), after your incapacity your agent may exercise authority under this power of attorney ONLY IF this document has been recorded, in the same manner as a deed, with the register of deeds in the county where you reside at the time it is recorded (or, if you reside out of state, in any South Carolina county where your property is located). Recording may happen before or after incapacity. BECAUSE THIS SPRINGING DOCUMENT OPERATES ONLY AFTER INCAPACITY, IT MUST BE RECORDED BEFORE YOUR AGENT CAN EVER ACT. Record it promptly after signing.

Reliance by Third Parties. This power of attorney contains the following provision, as S.C. Code § 62-8-120(b)(7) contemplates:

"No person who may act in reliance upon the representation of my agent for the scope of authority granted to the agent shall incur any liability to me or to my estate as a result of permitting the agent to exercise this authority, nor is any person who deals with my agent responsible to determine or ensure the proper application of funds or property."

Your agent is your fiduciary. Under S.C. Code § 62-8-114, your agent must act in your best interest, in good faith, and only within the authority granted, and must keep records of all receipts, disbursements, and transactions. Unless you elect otherwise in Article VI, your agent is entitled under S.C. Code § 62-8-112 to reimbursement of reasonable expenses AND compensation that is reasonable under the circumstances.

This document does NOT give anyone authority to make health care decisions for you. South Carolina health care decisions are made under a separate statutory health care power of attorney (S.C. Code Title 62, Article 5, Part 5).

You may revoke this power of attorney at any time while you have capacity. A revocation must be executed with the same formalities as this document (S.C. Code §§ 62-8-105, 62-8-106), and if this power of attorney was recorded, the revocation must also be recorded in the same county (S.C. Code § 62-8-110(g)). This document terminates at your death.

If there is anything about this document you do not understand, ask a South Carolina lawyer of your own choosing to explain it before you sign. You must have contractual capacity to sign (S.C. Code § 62-8-102(9)).

I have read or had explained to me this Notice and I understand its contents.

___________________________________________ __________________

(Signature of Principal) (Date)

ARTICLE I — APPOINTMENT OF AGENT

I, the undersigned principal:

Name: ____________________________________________________________

Address: ____________________________________________________________

designate the following person as my agent (attorney-in-fact), to act for me as provided in this power of attorney:

Name: ____________________________________________________________

Address: ____________________________________________________________

Telephone: ________________________________________________________

Co-agents (optional). I may name a second agent to serve at the same time: _______________________________________________. If I name two agents, then under S.C. Code § 62-8-111(a) EACH MAY ACT INDEPENDENTLY unless I check here: [ ] my two agents must act JOINTLY. If one of two co-agents fails or ceases to serve, the other may continue to act alone.

Successor agents (optional, recommended). If my agent resigns, dies, becomes incapacitated, is not qualified to serve, or declines to serve, I designate the following successor(s), each to act alone and successively in the order named, with the same authority (S.C. Code § 62-8-111(b)):

First successor: ____________________________________________________

Second successor: ____________________________________________________

ARTICLE II — EFFECTIVENESS AND DURABILITY

This power of attorney becomes effective only upon my incapacity (S.C. Code § 62-8-109(a)).

It is a durable power of attorney with postponed effectiveness. Until the written determination described below is made, my agent has NO authority over my property or financial affairs except the limited records-access authority described in this Article. Once effective, it is not terminated by my continued incapacity (S.C. Code § 62-8-104) and remains in effect until I revoke it or I die.

Definition of incapacity. For purposes of this power of attorney, I am incapacitated when I am unable to manage my property or business affairs because I: (A) have an impairment in the ability to receive and evaluate information or make or communicate decisions, even with the use of technological assistance; or (B) am missing; detained, including incarcerated in a penal system; or outside the United States and unable to return (S.C. Code § 62-8-102(5)).

OPTIONAL DESIGNATION OF DETERMINER. I may authorize one or more persons to determine in a writing or other record that my incapacity has occurred (S.C. Code § 62-8-109(a)(1)): Designee: ______________________________________________. Successor designee: ______________________________________________. This election is effective only if I BOTH initial here _______ AND name at least one person above. Each named person acts separately and in the order listed.

DEFAULT DETERMINATION. If no designation above is effective, or every named person is unable or unwilling to make the determination, this power of attorney becomes effective upon a determination in a writing or other record by: (A) a physician or licensed psychologist that I am incapacitated within the meaning of S.C. Code § 62-8-102(5)(A); or (B) an attorney at law, a court of competent jurisdiction, or an appropriate governmental official that I am incapacitated within the meaning of S.C. Code § 62-8-102(5)(B) (S.C. Code § 62-8-109(a)(2)). A determination form is attached as Exhibit B.

HIPAA AUTHORIZATION. Solely for determining whether this power of attorney has become effective: (1) each person I have designated above is my personal representative under the Health Insurance Portability and Accountability Act and may obtain and discuss my health information relevant to that determination (S.C. Code § 62-8-109(b); 45 C.F.R. § 164.502(g)); and (2) I authorize each physician or licensed psychologist who examines me for the determination described in this Article to obtain and discuss my health information to the extent needed to make that determination.

DELIVERY AND ATTACHMENT. The written determination of incapacity must be delivered to my agent and kept with (and, when presented, attached to) this power of attorney. My agent must also complete the Agent's Certification (Exhibit A), including its item (3), certifying that the event or contingency has occurred (S.C. Code § 62-8-119(f)(3)).

RECORDING GATE. Under S.C. Code § 62-8-109(c), even after a written determination of incapacity is made, my agent may NOT exercise authority under this power of attorney unless and until this document has been recorded with the register of deeds in the county where I reside at the time it is recorded (or, if I reside out of state, in any South Carolina county where my property is located). This document may be recorded before or after my incapacity. RECORD IT PROMPTLY AFTER SIGNING.

If I recover. If a determination of incapacity has been made but I later regain capacity, I may revoke this power of attorney or resume acting for myself by a written revocation executed with the same formalities as this document, recorded in the same county if this document was recorded (S.C. Code § 62-8-110(g)).

ARTICLE III — GRANT OF GENERAL AUTHORITY

I grant my agent general authority as described in S.C. Code § 62-8-201(c). As permitted by S.C. Code § 62-8-202(b), I incorporate by citation EACH of Sections 62-8-204 through 62-8-216 of the South Carolina Code, and each cited section is incorporated as if it were set out in full in this document. EACH CATEGORY BELOW IS GRANTED UNLESS I INITIAL ITS "WITHHOLD" BOX. Initialing WITHHOLD deletes that category from this grant. A blank WITHHOLD box means the category is granted.

A plain-English summary of each category follows; the cited statute controls. If grants overlap, the broadest authority controls (S.C. Code § 62-8-201(e)). This authority extends to property I have now or acquire later, wherever located (S.C. Code § 62-8-201(f)), and includes the related construction powers of S.C. Code § 62-8-203, including accessing my electronic files, user names, and passwords.

WITHHOLD _______ (1) Real property (S.C. Code § 62-8-204): buy, sell, lease, mortgage, manage, improve, and otherwise deal with real estate and rights in real estate.

WITHHOLD _______ (2) Tangible personal property (S.C. Code § 62-8-205): buy, sell, lease, store, repair, and otherwise deal with tangible personal property.

WITHHOLD _______ (3) Stocks and bonds (S.C. Code § 62-8-206): buy, sell, exchange, pledge, and vote securities and operate securities accounts.

WITHHOLD _______ (4) Commodities and options (S.C. Code § 62-8-207): operate commodity and option accounts (NOTE: dealing in commodity futures contracts and listed puts/calls itself is a Special Power that must be initialed in Article IV).

WITHHOLD _______ (5) Banks and other financial institutions (S.C. Code § 62-8-208): open, modify, and close accounts; deposit and withdraw funds; write and endorse checks; borrow; use safe-deposit services (NOTE: renting a box is included here; accessing a box already leased by me is a Special Power in Article IV).

WITHHOLD _______ (6) Operation of an entity or business (S.C. Code § 62-8-209): operate, buy, sell, and restructure business interests and sole proprietorships.

WITHHOLD _______ (7) Insurance and annuities (S.C. Code § 62-8-210): procure, continue, modify, borrow against, surrender, and collect on insurance and annuity contracts.

WITHHOLD _______ (8) Estates, trusts, and other beneficial interests (S.C. Code § 62-8-211): receive and manage inheritances and trust interests, and transfer my property into a revocable trust I have created.

WITHHOLD _______ (9) Claims and litigation (S.C. Code § 62-8-212): bring, defend, settle, and compromise claims and lawsuits, including bankruptcy matters.

WITHHOLD _______ (10) Personal and family maintenance (S.C. Code § 62-8-213): maintain the customary standard of living of me, my spouse, and my dependents, including health-care payment arrangements and facility admission contracts (this authority does not depend on any gift power).

WITHHOLD _______ (11) Benefits from governmental programs or civil or military service (S.C. Code § 62-8-214): apply for, manage, and appeal Social Security, Medicare, Medicaid, veterans, and other benefits.

WITHHOLD _______ (12) Retirement plans (S.C. Code § 62-8-215): elect payment options, make rollovers and contributions, and exercise plan rights.

WITHHOLD _______ (13) Taxes (S.C. Code § 62-8-216): prepare, sign, and file tax returns; pay taxes; contest deficiencies; and act before the IRS and other taxing authorities.

Digital assets. This power of attorney EXPRESSLY GRANTS my agent authority over my digital assets, INCLUDING THE CONTENT OF ELECTRONIC COMMUNICATIONS sent or received by me, as provided in S.C. Code §§ 62-2-1045 and 62-2-1050 (South Carolina Uniform Fiduciary Access to Digital Assets Act). A direction I have given through a custodian's online tool controls over this grant (S.C. Code § 62-2-1020).

OPTIONAL WITHHOLD (content of communications only): _______ My agent may NOT access the content of my electronic communications (catalogue and other digital assets remain granted).

ARTICLE IV — SPECIAL POWERS (GRANT ONLY BY INITIALING)

UNDER S.C. CODE § 62-8-201(a), MY AGENT HAS NONE OF THE FOLLOWING POWERS UNLESS I INITIAL THE LINE FOR THAT POWER. A blank line means the power is NOT granted. These powers can significantly change your estate plan or dissipate your property — initial only the powers you intend.

INITIAL _______ (1) Create, amend, revoke, or terminate a trust, pursuant to Section 62-7-602A — change or end trusts.

INITIAL _______ (2) Make a gift — give away my property (see the gift-limit election below).

INITIAL _______ (3) Create or change rights of survivorship — add or remove survivorship rights on accounts and property.

INITIAL _______ (4) Create or change a beneficiary designation — name or change who receives accounts, policies, or plans at my death.

INITIAL _______ (5) Delegate authority granted under this power of attorney — let my agent hand some or all authority to another person.

INITIAL _______ (6) Waive my right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan — give up survivor benefits.

INITIAL _______ (7) Exercise fiduciary powers that I have authority to delegate — act in my place as a trustee, executor, or other fiduciary.

INITIAL _______ (8) Disclaim property, including a power of appointment — refuse inheritances or property I am entitled to.

INITIAL _______ (9) Access a safe deposit box or vault leased by me — open and remove contents from my safe deposit box.

INITIAL _______ (10) Exercise a power of appointment in favor of someone other than me — direct who receives property under a power of appointment I hold.

INITIAL _______ (11) Reject, renounce, disclaim, release, or consent to a reduction in or modification of a share in or payment from an estate, trust, or other beneficial interest — reduce or give up a share or payment from an estate or trust.

INITIAL _______ (12) Deal with commodity futures contracts and call or put options on stocks or stock indexes — trade futures and listed options.

Self-dealing limit (S.C. Code § 62-8-201(b)). Unless this power of attorney otherwise provides, an agent who is NOT my ancestor, my spouse, or my descendant may NOT use powers (2), (3), (4), (8), or (11) to create in the agent, or in someone the agent is legally obligated to support, an interest in my property.

Gift-limit election (applies only if power (2) is initialed). Unless I initial the broader-authority line below, gift authority is limited as provided in S.C. Code § 62-8-217: gifts per recipient are capped at the annual federal gift-tax exclusion amount (twice that amount if my spouse consents to split gifts), and gifts must be consistent with my known objectives or my best interest, considering my property, my foreseeable needs, taxes, benefit eligibility, and my gifting history.

INITIAL _______ Broader gift authority. My agent may make gifts exceeding the S.C. Code § 62-8-217 limits, as instructed here: _______________________________________________

ARTICLE V — SPECIAL INSTRUCTIONS

I may delete from, add to, or modify the powers granted by this document as follows (if none, write "None"):

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

ARTICLE VI — COMPENSATION OF MY AGENT (S.C. CODE § 62-8-112)

Unless I check a box below, South Carolina law entitles my agent to BOTH reimbursement of expenses reasonably incurred on my behalf AND compensation that is reasonable under the circumstances (S.C. Code § 62-8-112).

[ ] Reimbursement only. My agent is NOT entitled to compensation for services. Reimbursement of reasonably incurred expenses remains payable.

[ ] Reimbursement plus reasonable compensation. My agent is entitled to reimbursement of reasonably incurred expenses plus reasonable compensation, as provided by S.C. Code § 62-8-112.

ARTICLE VII — NOMINATION OF CONSERVATOR OR GUARDIAN (OPTIONAL)

If protective proceedings for my estate or person are ever begun, I nominate the following person(s) for consideration by the court. Under S.C. Code § 62-8-108(a), except for good cause shown or disqualification, the court SHALL make its appointment in accordance with my most recent nomination in a power of attorney. (Leave blank to make no nomination.)

Conservator of my estate: ________________________________________________

Guardian of my person: ________________________________________________

SURVIVAL OF THIS POWER (S.C. Code § 62-8-108(b)). This power of attorney otherwise provides: the appointment of a conservator or guardian for me does NOT terminate this power of attorney or my agent's authority, unless a court of competent jurisdiction specifically so orders. My agent is accountable to any court-appointed fiduciary as provided by law.

ARTICLE VIII — RELIANCE AND THIRD PARTIES

Reliance provision. As quoted in the Notice, this power of attorney contains the provision described in S.C. Code § 62-8-120(b)(7):

"No person who may act in reliance upon the representation of my agent for the scope of authority granted to the agent shall incur any liability to me or to my estate as a result of permitting the agent to exercise this authority, nor is any person who deals with my agent responsible to determine or ensure the proper application of funds or property."

Duty to accept. Under S.C. Code § 62-8-120(a), a person presented with this acknowledged power of attorney must accept it, or request a certification, translation, or opinion of counsel, no later than seven (7) business days after presentation, and must accept it no later than five (5) business days after receiving a requested certification, translation, or opinion. A person may not require a different or additional form of power of attorney. A person who refuses in violation of that section is subject to a court order mandating acceptance and to liability for reasonable attorney's fees and costs (S.C. Code § 62-8-120(c)).

Reliance and copies. A person that in good faith accepts this acknowledged power of attorney without actual knowledge that it is void, invalid, or terminated, or that my agent is exceeding authority, may rely on it (S.C. Code § 62-8-119(b)). A photocopy or electronically transmitted copy of this power of attorney has the same effect as the original (S.C. Code § 62-8-106(d)). My agent may certify facts concerning this power of attorney under penalty of perjury using the form attached as Exhibit A (S.C. Code § 62-8-119(f)).

How my agent signs. When my agent signs an instrument on my behalf, the signature should identify me and show the agency, for example: "[My name], by [Agent's name], as agent (attorney-in-fact), under power of attorney dated ____________ and recorded in ____________ County, South Carolina."

ARTICLE IX — REVOCATION; EFFECT ON PRIOR POWERS OF ATTORNEY

Revocation. I may revoke this power of attorney by a written revocation executed with the same formalities as this document (S.C. Code §§ 62-8-105, 62-8-106). If this power of attorney was recorded, the revocation must ALSO be recorded in the same county (S.C. Code § 62-8-110(g)). Termination is not effective as to a person who acts in good faith without actual knowledge of it (S.C. Code § 62-8-110(d)). If my agent resigns and this power of attorney was recorded, the resignation must also be recorded in the same location (S.C. Code § 62-8-118(c)).

Divorce. If my spouse is my agent, my spouse's authority terminates if our marriage is dissolved or annulled, as provided in S.C. Code §§ 62-8-110(b)(3) and 62-2-507, unless this power of attorney provides otherwise. This document does not provide otherwise.

Prior powers of attorney (S.C. Code § 62-8-110(f)). Executing this document does NOT revoke my earlier powers of attorney unless I so provide. I elect (check ONE):

[ ] REVOKE all of my earlier powers of attorney concerning property and financial matters (this does not revoke any health care power of attorney);

[ ] REVOKE only the following earlier power(s) of attorney: _______________________________________________;

[ ] DO NOT revoke my earlier powers of attorney.

ARTICLE X — GOVERNING LAW AND SEVERABILITY

This power of attorney is governed by the South Carolina Uniform Power of Attorney Act, S.C. Code Title 62, Article 8, and the laws of the State of South Carolina (S.C. Code § 62-8-107). The probate court has concurrent jurisdiction with the circuit courts over matters related to this power of attorney (S.C. Code § 62-8-401). If any provision of this document is held invalid or unenforceable, the remaining provisions continue in full force.

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EXECUTION

South Carolina execution requirements (S.C. Code § 62-8-105): this power of attorney must be (1) signed by me (or by another person I direct, in my presence), (2) attested with the same formality and witness requirements as a South Carolina will — TWO WITNESSES — and (3) acknowledged before a notary public or other officer authorized to administer oaths (S.C. Code § 30-5-30). PLAN FOR ONE SIGNING CEREMONY: you, your two witnesses, and the notary, all present together. Witnesses should be adults who are NOT named as agent or successor agent in this document and not the spouse of an agent or successor.

___________________________________________ __________________

(Signature of Principal) (Date)

ATTESTATION OF WITNESSES

Each of the undersigned witnesses declares that the principal signed this power of attorney, or acknowledged the principal's signature or this instrument, in the witness's presence, and that each witness signs below as a witness. To each witness's knowledge the principal has contractual capacity and is acting voluntarily.

Witness 1 signature: __________________________________ Date: ______________

Witness 1 printed name: _______________________________________________

Witness 1 address: _____________________________________________________

Witness 2 signature: __________________________________ Date: ______________

Witness 2 printed name: _______________________________________________

Witness 2 address: _____________________________________________________

NOTARY ACKNOWLEDGMENT (S.C. Code § 30-5-30)

South Carolina,

____________________ County.

I, ____________________________________________ (name of officer and official title), do hereby certify that ____________________________________________ (name of principal), personally appeared before me this day, in the presence of the two witnesses named above, and acknowledged the due execution of the foregoing instrument.

[ ] Check only if applicable: the principal's signature above was made by another individual in the principal's presence and at the principal's direction (S.C. Code § 62-8-105(1)).

Witness my hand and official seal this the ______ day of ____________________, 20____.

_____________________________________________ (Seal)

Signature of Officer (Notary Public)

My commission expires: ____________________

RECORDER'S BLOCK (complete before recording)

This document prepared by: ____________________________________________________________

After recording, return to: ____________________________________________________________

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AGENT'S DUTIES — A SUMMARY FOR THE PERSON I HAVE NAMED

A person accepts appointment as agent by exercising authority, performing duties, or otherwise indicating acceptance (S.C. Code § 62-8-113). An agent who accepts appointment must, under S.C. Code § 62-8-114:

• act in accordance with my reasonable expectations actually known to the agent, in my best interest, in good faith, and only within the scope of authority granted;

• act loyally for my benefit and avoid conflicts of interest that impair impartial action in my best interest;

• act with the care, competence, and diligence ordinarily exercised by agents in similar circumstances;

• keep a record of all receipts, disbursements, and transactions made on my behalf;

• cooperate with the person who has authority to make health care decisions for me; and

• attempt to preserve my estate plan, to the extent actually known, if consistent with my best interest, considering the value and nature of my property, my foreseeable obligations and need for maintenance, tax minimization, and eligibility for benefits and programs.

An agent who has actual knowledge of a breach of fiduciary duty by another agent must notify me and, if I am incapacitated, take reasonably appropriate action to safeguard my best interest (S.C. Code § 62-8-111(d)).

An agent must disclose receipts, disbursements, and transactions within 30 days of a request by me, my guardian or conservator, another fiduciary acting for me, a government agency with authority to protect my welfare, or, after my death, my personal representative (S.C. Code § 62-8-114(h)).

Authority over personal and family maintenance (if granted) does not depend on and is not limited by any gift authority (S.C. Code § 62-8-213(b)). An agent who violates the Act is liable to restore losses and reimburse attorney's fees and costs (S.C. Code § 62-8-117).

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EXHIBIT A — AGENT'S CERTIFICATION AS TO THE VALIDITY OF POWER OF ATTORNEY AND AGENT'S AUTHORITY (S.C. CODE § 62-8-119(F))

State of ____________________

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) the action I desire to take is within the scope of my authority granted under the Power of Attorney;

(3) the Power of Attorney was drafted to become effective upon the happening of an event or contingency, and the event or contingency HAS OCCURRED (the written determination of incapacity required by Article II of the Power of Attorney is attached);

(4) if I was named as a successor agent, the prior agent is no longer able or willing to serve; and

(5) ______________________________________________________________________________________

______________________________________________________________________________________ (Insert Other Relevant Statements)

___________________________________________ __________________

(Agent's Signature) (Date)

Agent's name printed: ____________________________________________

Agent's address: ____________________________________________

Agent's telephone number: ____________________________________________

This document was acknowledged before me on ____________________ (Date) by ____________________________________________ (Name of Agent).

_____________________________________________ (Seal, if any)

Signature of Notary

My commission expires: ____________________

[This document prepared by: ____________________________________________]

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EXHIBIT B — WRITTEN DETERMINATION OF INCAPACITY (S.C. CODE § 62-8-109(A))

This form activates the attached springing power of attorney. It is completed by the person the principal designated in Article II of the power of attorney or, if no designation is effective or the designee is unable or unwilling, by a physician or licensed psychologist (for impairment determinations) or an attorney at law, court, or appropriate governmental official (for missing/detained/abroad determinations). The completed determination must be delivered to the agent and kept with the power of attorney. REMEMBER: the agent may not act until the power of attorney is also RECORDED as required by S.C. Code § 62-8-109(c).

I, ____________________________________________, determine in writing that ____________________________________________ (the principal) is incapacitated as defined in Article II of the attached power of attorney — that is, unable to manage the principal's property or business affairs because of a cause described in S.C. Code § 62-8-102(5).

My capacity to make this determination (check one):

[ ] I am the person designated by the principal in Article II of the power of attorney (or the successor designee).

[ ] I am a licensed physician. License no.: ____________________ State: ______

[ ] I am a licensed psychologist. License no.: ____________________ State: ______

[ ] I am an attorney at law, a court of competent jurisdiction, or an appropriate governmental official, and the principal is missing, detained, or outside the United States and unable to return (S.C. Code § 62-8-102(5)(B)). Details: _______________________________________________

Basis for my determination (examination, records reviewed, relationship, or other):

________________________________________________________________

________________________________________________________________

___________________________________________ __________________

(Signature of person making the determination) (Date)