Connecticut Durable Statutory Power of Attorney - Short Form

DURABLE STATUTORY POWER OF ATTORNEY

SHORT FORM

Conn. Gen. Stat. § 1-352(a)(2)

Notice: The powers granted by this document are broad and sweeping. They are defined in the Connecticut Uniform Power of Attorney Act, which expressly permits the use of any other or different form of power of attorney desired by the parties concerned. The grantor of any power of attorney or the agent may make application to a Probate Court for an accounting as provided in subsection (d) of section 45a-175 of the general statutes. This power of attorney does not authorize the agent to make health care decisions for you.

Know All Persons by These Presents, which are intended to constitute a GENERAL POWER OF ATTORNEY pursuant to the Connecticut Uniform Power of Attorney Act:

That I ____________________________________________ (insert name and address of the principal)

do hereby appoint ________________________________________ (insert name and address of the agent, or each agent, if more than one is designated)

my agent(s) TO ACT __________________.

If more than one agent is designated and the principal wishes each agent alone to be able to exercise the power conferred, insert in this blank the word 'severally'. Failure to make any insertion or the insertion of the word 'jointly' shall require the agents to act jointly.

First:

In my name, place and stead in any way which I myself could do, if I were personally present, with respect to the following matters as each of them is defined in the Connecticut Uniform Power of Attorney Act to the extent that I am permitted by law to act through an agent:

(Strike out and initial in the opposite box any one or more of the subparagraphs as to which the principal does NOT desire to give the agent authority. Such elimination of any one or more of subparagraphs (A) to (M), inclusive, shall automatically constitute an elimination also of subparagraph (N).)

To strike out any subparagraph the principal must draw a line through the text of that subparagraph AND write his initials in the box opposite.

(___) (A) Real property

(___) (B) Tangible personal property

(___) (C) Stocks and bonds

(___) (D) Commodities and options

(___) (E) Banks and other financial institutions

(___) (F) Operation of entity or business

(___) (G) Insurance and annuities

(___) (H) Estates, trusts and other beneficial interests

(___) (I) Claims and litigation

(___) (J) Personal and family maintenance

(___) (K) Benefits from governmental programs or civil or military service

(___) (L) Retirement plans

(___) (M) Taxes

(___) (N) All other matters

Special provisions and limitations (optional): ________________________________________________________________________

________________________________________________________________________

(Special provisions and limitations may be included in the statutory form power of attorney only if they conform to the requirements of the Connecticut Uniform Power of Attorney Act.)

Second: LIMITATION ON AGENT'S AUTHORITY

An agent MAY NOT use my property to benefit the agent or a dependent of the agent unless I have included that authority in any special instructions below.

Third:

Hereby ratifying and confirming all that said agent(s) or substitute(s) do or cause to be done.

Fourth:

With full and unqualified authority to exercise or delegate any or all of the foregoing powers granted under this power of attorney to any person or persons whom my agent(s) shall select.

Fifth: 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: ____________________________________________________

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: ____________________________________________________

Sixth: DESIGNATION OF CONSERVATOR OF ESTATE (OPTIONAL)

If a conservator of my estate should be appointed, I designate that ____________________________ be appointed to serve as conservator of my estate. If

______________________ is unable to serve or cease to serve as conservator of my estate, I designate that ______________________ be appointed to serve as conservator of my estate.

I direct that bond for the conservator of my estate, including any sureties thereon:

(___) be required

(___) not be required

(Initial ONE of the bond choices above.)

Seventh: EFFECTIVE DATE

This power of attorney is effective immediately unless I have stated otherwise in the special instructions.

The execution of this statutory short form power of attorney shall be duly acknowledged by the principal in the manner prescribed for the acknowledgment of a conveyance of real property.

SIGNATURE AND ACKNOWLEDGMENT

In Witness Whereof I have hereunto signed my name and affixed my seal this __________ day of __________________, 20____.

Signature of Principal: ____________________________________________

(Seal)

Witness Witness Signature: ____________________________________________

Witness Name Printed: ____________________________________________

Witness Witness Signature: ____________________________________________

Witness Name Printed: ____________________________________________

State of ____________________________________

County of ____________________________________

On this the __________ day of ________________, 20____, before me, ____________________________ (name of the principal), signer of the foregoing instrument, personally appeared, and acknowledged the execution of such instrument to be his/her free act and deed.

Signature of Notary / Commissioner of the Superior Court: ____________________________________

(Seal, if any)

My commission expires: ________________________________

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 continues until you resign or the power of attorney is terminated or revoked. You must:

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 through divorce or annulment, 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 the Connecticut Uniform Power of Attorney Act, sections 1-350 to 1-353b, inclusive. If you violate the Connecticut Uniform Power of Attorney Act, sections 1-350 to 1-353b, inclusive, 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 AS TO THE VALIDITY OF POWER OF ATTORNEY AND AGENT'S AUTHORITY

Conn. Gen. Stat. § 1-352a

State of ____________________________________

County of ____________________________________

I, ________________________________________ (Name of Agent), certify under penalty of false statement 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. Other relevant statements:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

SIGNATURE AND ACKNOWLEDGMENT

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).

Signature of Commissioner of Superior Court / Notary: ____________________________________

(Seal, if any)

My commission expires: ________________________________