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

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

SIGNING & USE GUIDE — READ FIRST, THEN REMOVE BEFORE SIGNING OR RECORDING

Utah Statutory Form Power of Attorney (Effective Upon Incapacity)

Prepared to the Utah Uniform Power of Attorney Act, Utah Code Title 75A, Chapter 2 (statutory form, § 75A-2-301; renumbered from Title 75, Chapter 9 effective September 1, 2024). This guide and the marked packet pages are not part of the statutory form. The power of attorney itself begins on the page titled "UTAH STATUTORY FORM POWER OF ATTORNEY."

(Utah Code, Title 75A, Chapter 2 — Uniform Power of Attorney Act)

What this document is

This is the Utah statutory form power of attorney for property and finances. It lets you (the "principal") name a person you trust (your "agent") to manage your property and financial matters. It is built on the form the Utah Legislature published at Utah Code § 75A-2-301, so it carries the meaning and effect the Uniform Power of Attorney Act prescribes, and third parties are required to accept an acknowledged power of attorney on the timetable in §§ 75A-2-119 and 75A-2-120.

This document does NOT authorize your agent to make health-care decisions for you. Utah health-care decisions use a separate advance health care directive.

Durable — and how Utah is different

This variant is DURABLE and SPRINGING: it takes effect only upon your later incapacity, and it remains effective during that incapacity. Utah is a default-durability state (§ 75A-2-104) — the power automatically continues through incapacity unless the document says it terminates then. The Special Instructions on this form carry the springing statement (§ 75A-2-109(1)) and name the person you choose to make the written incapacity determination (§ 75A-2-109(2)), with the statutory fallback (§ 75A-2-109(3)) recited.

A springing power can be slower to use: before acting, your agent may be asked for a written determination that you are incapacitated. Under § 75A-2-109(4), the person you authorize in the power of attorney to make that determination may act as your personal representative under HIPAA to obtain the health information needed. This packet also includes a standalone HIPAA authorization so both the named determiner and any fallback physician, attorney, judge, or governmental official can obtain that information — and only for that purpose.

Choose a determiner who is NOT your agent. The law permits your agent to make the determination, but the person best placed to certify the event that empowers your agent is someone independent — for example, your physician. If you need room for instructions beyond the printed lines, add a sheet titled "Special Instructions (continued)," sign and date it, and keep it with the power of attorney.

How to complete and sign

1. Fill in your name and your agent's name, address, and telephone number. 2. (Recommended) Name a successor agent, and optionally a second successor, in case your first choice cannot serve. 3. Under GRANT OF GENERAL AUTHORITY, INITIAL each subject you want your agent to handle — or initial "All Preceding Subjects" to grant them all. 4. Under GRANT OF SPECIFIC AUTHORITY, INITIAL only the specific powers you want to give; your agent may NOT do any of those unless you initial it. 5. Add any Special Instructions. 6. Sign before a notary public or other officer authorized to take acknowledgments (§ 75A-2-105(1)(a)). Someone else may sign your name for you in your conscious presence at your direction. Utah does not require witnesses. A notarized (acknowledged) signature is presumed genuine (§ 75A-2-105(1)(b)).

Capacity. You must have sufficient mental capacity when you sign to understand that you are appointing an agent to handle your financial affairs (§ 75A-2-105(1)(a)(ii)); you do not need to understand how the agent will manage them (§ 75A-2-105(1)(c)). Sign now: a springing power must still be SIGNED while you have that capacity — you cannot wait for disability to execute this document.

Electronic signing. Utah's Uniform Electronic Estate Planning Documents Act (Title 75, Chapter 13, effective May 6, 2026) permits a durable power of attorney to be signed electronically unless the document precludes it. Because banks and recorders still prefer a wet-ink original with a notarial acknowledgment, this packet is designed to be printed and signed on paper.

One Utah rule that surprises people

Care-facility employees. If you live in — or are about to move into — a hospital, assisted living, skilled nursing, or similar facility when you sign, you may NOT name that facility's owner, operator, health care provider, or employee as your agent, unless that person is your spouse, legal guardian, or next of kin, or the authority is strictly limited to helping you establish Medicaid eligibility (§ 75A-2-105(2)). Naming a barred person is a crime under § 76-5-111.4 — even though it does not by itself make the document invalid. If this bar applies to your situation, name someone else.

Powers your agent has only if you initial them

The eight "specific authority" powers (create, amend, revoke, or terminate a trust; make gifts; change survivorship or beneficiary designations; delegate authority; waive a joint-and-survivor annuity; exercise fiduciary powers; or disclaim property) are never granted by a general grant — you must initial each one you want (§ 75A-2-201(1)).

Gifts. Even if you initial "Make a gift," Utah caps a general gift grant at the federal gift-tax annual exclusion per recipient (26 U.S.C. § 2503(b)), or double that with split-gift consent, unless you provide otherwise in Special Instructions (§ 75A-2-217). Gifts must also be consistent with your known objectives or best interest.

Self-dealing. Unless you provide otherwise in Special Instructions, an agent who is not your ancestor, spouse, or descendant may not use your property to benefit themselves or someone they must support (§ 75A-2-201(2)). Initialing "Make a gift" alone does not lift that bar for a non-relative agent.

Digital assets. Initialing "All Preceding Subjects" already lets your agent obtain a catalogue of your electronic communications and your other digital assets (§ 75A-6-110). But a custodian may disclose the CONTENT of your emails and messages only if the power of attorney expressly grants that authority (§ 75A-6-109). If you want your agent to have it, add to Special Instructions: "My agent has authority over the content of electronic communications sent or received by me, pursuant to Utah Code § 75A-6-109."

What ends the power — and what does not

The power ends when you die, when you revoke it, or when no agent is available to act (§ 75A-2-110(1)). Two Utah rules surprise people:

• A divorce filing ends a spouse-agent's authority. If your agent is your spouse, the filing of an action for divorce or annulment or for legal separation ends the agent's authority — unless the power of attorney says otherwise (§ 75A-2-110(2)(c)).

• A court-appointed conservator does NOT end it. If a court later appoints a conservator or guardian, your power of attorney continues and your agent simply becomes accountable to that fiduciary as well as to you, unless the court limits, suspends, or terminates it (§ 75A-2-108(4)). The nomination block on the form tells the court whom you want appointed (§ 75A-2-108(3)).

Signing a NEW power of attorney does NOT revoke an earlier one unless the new document says so (§ 75A-2-110(6)). If you want this power of attorney to replace earlier ones, add to the Special Instructions: "I revoke all powers of attorney I previously executed." Otherwise, to revoke a prior power, use the Revocation of Power of Attorney included in this packet (Utah has no statutory revocation form; revocation is governed by § 75A-2-110(7)) and deliver copies to your agent, any successor agents, and every institution that has the old one — revocation is not effective as to someone who acts in good faith without actual knowledge of it (§ 75A-2-110(4)). If the old power was recorded, record the revocation in the same county recorder's office.

If a bank or other institution hesitates

Utah law requires a person to accept an acknowledged power of attorney — or to request an agent's certification, an English translation, or an opinion of counsel — within seven business days, and to accept within five business days after receiving the requested item. They may not demand their own different form. One who refuses without a statutory ground can be ordered to accept it and to pay attorney fees and costs (§§ 75A-2-119, 75A-2-120). The Agent's Certification in this packet (statutory form, § 75A-2-302) is the document your agent signs for that purpose.

Your agent's duties

By accepting, your agent must act in your best interest, in good faith, and only within the authority granted — and must disclose the agency relationship by signing "(Your Name) by (Agent's Signature) as Agent" (§ 75A-2-114(1)). Unless you provide otherwise, your agent must also act loyally, avoid conflicts, use care, keep a record of every receipt, disbursement, and transaction, cooperate with your health-care decision maker, and try to preserve your estate plan (§ 75A-2-114(2)) — and must answer a proper request for an accounting within 30 days (§ 75A-2-114(8)). Your agent is entitled to reimbursement and reasonable compensation unless you say otherwise in Special Instructions (§ 75A-2-112). Naming co-agents? They may act independently unless you require them to act together in Special Instructions (§ 75A-2-111(1)).

Recording (real estate)

You do not need to record this power of attorney for it to be valid. If your agent will sign a deed or other real-property document, record the acknowledged original with the county recorder where the property is located, as part of that transaction. To record a COPY instead of the original, the person who accepts the power of attorney (the title company or other relying party — not you and not your agent in the agent's own right) attaches the affidavit described in § 75A-2-106(4); an optional Affidavit of Person Accepting Power of Attorney is included in this packet for that purpose.

Utah has statewide recorder formatting rules (§§ 17-71-402 and 17-71-403, renumbered effective November 6, 2025). Every recorded document needs a brief title on its first page, a legible notary stamp, original signatures, and a typed or printed name beneath each signature; most counties also require white 8½×11 paper, 1-inch margins, black ink, and a 2½-by-4½-inch blank space at the upper right corner of the first page. The statutory form itself already carries its title, acknowledgment, and printed-name lines. If you record, place this packet's optional Recording Cover Page (which supplies the corner space, return-to block, parcel-number line, and legal description area) on top as page 1. A formatting objection at the recorder's office does not affect the validity of the power of attorney itself.

Keep it safe

Sign one original and keep it where your agent can reach it. Give a copy to your agent and to any institution that will rely on it — a photocopy or electronically transmitted copy has the same effect as the original (§ 75A-2-106(4)). Documents signed before September 1, 2024 that cite the former Title 75, Chapter 9 sections remain valid — the renumbering did not disturb them (§ 75A-1-102). Review the document every few years and after major life events.

This guide is general information, not legal advice. If your situation is complex — substantial gifts, tax or public-benefit planning, business interests, or a blended family — consult a Utah attorney.

UTAH

STATUTORY FORM POWER OF ATTORNEY

Utah Code Title 75A, Chapter 2, Uniform Power of Attorney Act (§ 75A-2-301)

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 Title 75A, Chapter 2, Uniform Power of Attorney Act.

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 or is unable to act for you.

Your agent is entitled to reasonable compensation unless you state otherwise in the Special Instructions.

This form provides for designation of one agent. If you wish to name more than one agent you may name a coagent in the Special Instructions. Coagents are not 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 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 legal advice 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: ___________________________________________

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: ____________________________________

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: _____________________________

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 Title 75A, Chapter 2, Uniform Power of Attorney Act:

(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 MAY 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 you WANT to give your agent.)

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

(___) Make a gift, subject to the limitations of Section 75A-2-217, 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

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

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

LIMITATION ON AGENT'S AUTHORITY

An agent that is not my ancestor, spouse, or descendant MAY 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)

This power of attorney becomes effective only upon my incapacity, as provided in Utah Code § 75A-2-109(1). I authorize the following person(s), pursuant to § 75A-2-109(2), to determine in a writing or other record that I am incapacitated:

Name of Determiner: ________________________________________________

Determiner's Address: _____________________________________________

Determiner's Telephone Number: ______________________________________

If no person I have authorized is able or willing to make the determination, my incapacity may be determined in a writing or other record by a physician, or by an attorney at law, a judge, or an appropriate governmental official, as provided in § 75A-2-109(3). Each person who makes the determination, whether named above or acting under that fallback, may act as my personal representative under HIPAA (42 U.S.C. § 1320d et seq.) to obtain access to my health care information and communicate with my health care providers, solely to make that determination (§ 75A-2-109(4)).

You may give additional special instructions on the following lines:

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

EFFECTIVE DATE

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

NOMINATION OF CONSERVATOR OR GUARDIAN (OPTIONAL)

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

Name of Nominee for conservator of my estate: ______________________________

Nominee's Address: _________________________________________________

Nominee's Telephone Number: ________________________________________

Name of Nominee for guardian of my person: _____________________________

Nominee's Address: _________________________________________________

Nominee's Telephone Number: ________________________________________

RELIANCE ON THIS POWER OF ATTORNEY

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

SIGNATURE AND ACKNOWLEDGMENT

____________________________________________ _______________

Your SignatureDate

____________________________________________

Your Name Printed

____________________________________________

Your Address

____________________________________________

Your Telephone Number

State of ______________________________

County of _____________________________

This document was acknowledged before me on __________________________,

(Date)

by ______________________________________.

(Name of Principal)

____________________________________________ (Seal, if any)

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 shall:

(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; and

(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: (Principal's Name) by (Your Signature) as Agent

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; and

(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 the power of attorney or your authority;

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

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

(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 Title 75A, Chapter 2, Uniform Power of Attorney Act. If you violate Title 75A, Chapter 2, Uniform Power of Attorney Act, 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.

AGENT'S CERTIFICATION (UTAH CODE § 75A-2-302 STATUTORY FORM)

The following optional form (Utah Code § 75A-2-302) may be used by an agent to certify facts concerning a power of attorney. Use it when a bank, title company, or other person asks for proof that the power of attorney is still in effect (§§ 75A-2-119(4), 75A-2-120).

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

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) 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 statements)

SIGNATURE AND ACKNOWLEDGMENT

____________________________________________ _______________

Agent's SignatureDate

____________________________________________

Agent's Name Printed

____________________________________________

Agent's Address

____________________________________________

Agent's Telephone Number

State of ______________________________

County of _____________________________

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: _____________________________________________

AGENT'S CERTIFICATION (UTAH CODE § 75A-2-302 STATUTORY FORM) — SPARE BLANK COPY

The following optional form (Utah Code § 75A-2-302) may be used by an agent to certify facts concerning a power of attorney. Use it when a bank, title company, or other person asks for proof that the power of attorney is still in effect (§§ 75A-2-119(4), 75A-2-120).

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

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) 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 statements)

SIGNATURE AND ACKNOWLEDGMENT

____________________________________________ _______________

Agent's SignatureDate

____________________________________________

Agent's Name Printed

____________________________________________

Agent's Address

____________________________________________

Agent's Telephone Number

State of ______________________________

County of _____________________________

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: _____________________________________________

REVOCATION OF POWER OF ATTORNEY — COMPANION DOCUMENT (REMOVE FROM THE SIGNED POWER OF ATTORNEY; USE ONLY IF YOU REVOKE)

Utah has no statutory revocation form. Under Utah Code § 75A-2-110(7), you may revoke a power of attorney by any method that manifests clear and convincing evidence of your intent. This ILRG-drafted form is designed to do that. It is not part of the statutory form power of attorney.

REVOCATION OF POWER OF ATTORNEY

I, __________________________________________, of

_______________________________________________________

(Name of Principal) (Address)

revoke the power of attorney dated ______________________, in

which I named ______________________________________ as my

agent, and I revoke the authority of every agent and successor agent named in that power of attorney.

(___) OPTIONAL — I also revoke every other power of attorney I have previously executed (Utah Code § 75A-2-110(6): a later power of attorney does not revoke an earlier one unless it so provides).

I intend this revocation to manifest clear and convincing evidence of my intent under Utah Code § 75A-2-110(7). Any person may rely on this revocation upon receiving it. Acts taken in good faith without actual knowledge of this revocation remain binding as provided in § 75A-2-110(4).

If the revoked power of attorney was recorded with a county recorder, record this revocation in the same county, and deliver a copy to every person or institution that has or may rely on the revoked power of attorney.

____________________________________________ _______________

Your SignatureDate

____________________________________________

Your Name Printed

Notarization is recommended so this revocation can be recorded and relied upon.

State of ______________________________

County of _____________________________

This document was acknowledged before me on __________________________,

(Date)

by ______________________________________.

(Name of Principal)

____________________________________________ (Seal, if any)

Signature of Notary

My commission expires: ________________________

OPTIONAL RECORDING COVER PAGE — USE ONLY AS PAGE 1 WHEN YOU RECORD THIS POWER OF ATTORNEY. NOT PART OF THE STATUTORY FORM.

(County recorder use: the upper-right 2½ inches down × 4½ inches across of this page is intentionally left blank for recording data — Utah Code § 17-71-402(4)(a)(iii).)

POWER OF ATTORNEY

(Cover page for recording — Utah Code § 17-71-402(3)(c) brief title)

Principal (name as signed on the power of attorney): ______________________________

Agent: ______________________________________________________________

When recorded, return to:

Name: __________________________________________________________

Address: ________________________________________________________

City, State, ZIP: ________________________________________________

County where property is located (real-estate recording): ______________________

Tax serial / parcel number, if the recorder requires it (§ 17-71-402(5)): ________________

Legal description of the property (or "See attached Exhibit A"):

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Remove this page before signing or storing the power of attorney. Use it only as the top page of the set you hand to the county recorder.

AFFIDAVIT OF PERSON ACCEPTING POWER OF ATTORNEY — OPTIONAL COMPANION (UTAH CODE § 75A-2-106(4)). SIGNED BY THE PERSON ACCEPTING THE POWER OF ATTORNEY — NOT BY THE PRINCIPAL.

Utah Code § 75A-2-106(4) gives a photocopy or electronically transmitted copy of a power of attorney the same effect as the original, and lets the copy be recorded in the county where a real-property transaction lies when it is attached to an affidavit of the person accepting the power of attorney. The title company, bank, or other relying party signs this affidavit. It is not part of the statutory form.

AFFIDAVIT OF PERSON ACCEPTING POWER OF ATTORNEY

I, ________________________________________,

______________________________ (title/role) of ________________________

(Name of person accepting) (Institution)

being first duly sworn, state:

1. On ____________________ (date), I accepted for reliance, on behalf of the person or institution named above, the power of attorney dated __________________,

executed by __________________________________ (Name of Principal),

naming ________________________________________ as agent.

2. The copy attached to this affidavit is a true and correct photocopy or electronically transmitted copy of the power of attorney I accepted.

3. This affidavit is made under Utah Code § 75A-2-106(4) so that the attached copy may be recorded in the county where the transaction lies.

____________________________________________ _______________

SignatureDate

____________________________________________

Name Printed

State of ______________________________

County of _____________________________

Subscribed and sworn to before me on ______________________,

(Date)

by ______________________________________.

(Name of person accepting)

____________________________________________ (Seal, if any)

Signature of Notary

My commission expires: ________________________

LIMITED HIPAA AUTHORIZATION — COMPANION DOCUMENT (NOT PART OF THE STATUTORY FORM)

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION FOR INCAPACITY DETERMINATION

Utah Code § 75A-2-109(4) lets a person whom you authorize in your power of attorney to determine your incapacity act as your personal representative under HIPAA for that purpose. This separate authorization makes that access explicit for the person you named in the Special Instructions of your power of attorney — and for a physician, attorney at law, judge, or appropriate governmental official who makes the determination under the § 75A-2-109(3) fallback. Sign it when you sign the power of attorney and keep them together.

I, __________________________________________ (Name of Principal),

authorize each of my health care providers to disclose my protected health information — limited to information reasonably needed to determine whether I am incapacitated within the meaning of Utah Code § 75A-2-102(8) — to:

(1) the person(s) named in the Special Instructions of my power of attorney to determine that I am incapacitated; and

(2) if no such person is able or willing, a physician, an attorney at law, a judge, or an appropriate governmental official acting under Utah Code § 75A-2-109(3),

and to communicate with that person about that determination. This authorization is given under 45 C.F.R. § 164.508 and Utah Code § 75A-2-109(4), is revocable by me in writing at any time except to the extent a provider has relied on it, and expires when my power of attorney terminates. It does NOT authorize anyone to make health-care decisions for me. Information disclosed may be subject to redisclosure by the recipient.

____________________________________________ _______________

Your SignatureDate

____________________________________________

Your Name Printed