NEW HAMPSHIRE GENERAL (FINANCIAL) POWER OF ATTORNEY

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.

DESIGNATION OF AGENT

I, __________________________________________________________ name the following person as my agent:
______________________________________________________________________

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: _____________________________________________________
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 NH § 564-E:201.

(CHECK 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 check “All Preceding Subjects” instead of checking 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 CHECKED 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. CHECK 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 the Uniform Power of Attorney Act 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)

You may give 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 or guardian of my estate or guardian of my person, I nominate the following person(s) for appointment:
Name of Nominee for conservator or guardian 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 Signature: __________________________________________ Date: _________

Your Printed Name: _____________________________________________________

Your Address: __________________________________________________________
______________________________________________________________________
Your Telephone Number: _____________________________________

STATEMENT OF WITNESS

On the date written above, the principal declared to me in my presence that this instrument is his general durable power of attorney and that he or she had willingly signed or directed another to sign for him or her, and that he or she executed it as his or her free and voluntary act for the purposes therein expressed.

WITNESS No. 1

Signature: _____________________________________________________________

Printed Name: __________________________________________________________

Address: ______________________________________________________________
______________________________________________________________________
WITNESS No. 2:

Signature: _____________________________________________________________

Printed Name: __________________________________________________________

Address: ______________________________________________________________
______________________________________________________________________

CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC

State of New Hampshire
County of _______________________

Acknowledged before me this _____ day of _______________ (month), 20___(year) by _________________________________ (name of principal). The affiant is (choose one):  personally known to me, or  produced the following identification:
__________________________________________________________________

Signature of Notary: _____________________________________________________
My commission expires: __________________________

(Seal, if any)