NEW YORK GENERAL (FINANCIAL) POWER OF ATTORNEY FORM
I.	NOTICE - This legal document grants you (Hereinafter referred to as the “Principal”) the right to transfer limited financial powers to someone else (Hereinafter referred to as the “Attorney-in-Fact”), limited financial powers are described as: any specific financial act legal under law. The Principal’s transfer of limited financial powers to the Attorney-in-Fact are granted upon authorization of this agreement, and ONLY remains in effect until the completion of said act, unless the Principal becomes incapacitated (incapacitation is described in Paragraph II). This agreement does not authorize the Attorney- in-Fact to make medical decisions for the Principal. The Principal continues to retain every right to all their financial decision making power and may revoke this Limited Power of Attorney Form at anytime. The Principal may include restrictions or requests pertaining to the financial decision making power of the Attorney-in-Fact. It is the intent of the Attorney-in-Fact to act in the Principal’s wishes put forth, or, to make financial decisions that fit the Principal’s best interest. All parties authorizing this agreement must be at least 18 years of age and acting under no false pressures or outside influences. Upon authorization of this Limited Power of Attorney Form, it will revoke any previously valid Limited Power of Attorney Form.

II.	INCAPACITATION – The powers granted to the Attorney-in-Fact by the Principal in this Limited Power of Attorney Form DO NOT stay in effect upon incapacitation by the Principal, incapacitation is describes as: A medical physician stating verbally or in writing that the Principal can no longer make decisions for them self.

III.	REVOCATION - The Principal has the right to revoke this Limited Power of Attorney Form at anytime. Any revocation will be effective if the Principal:
A.	Authorizes a new Limited Power of Attorney Form.
B.	Authorizes a Power of Attorney Revocation Form.

IV.	NOTARY - This document is not valid as a Limited Power of Attorney unless it is acknowledged before a notary public who is present when the Principal signs or acknowledges the Principal’s signature.

V.	PRINCIPAL - I,

Name of Principal

Street Address of Principal

, residing at

City of 	, State of 	, appoint
City of Principal	State of Principal
the following as my Attorney-in-Fact, whom I trust with a specific financial act or acts immediately upon the authorization of this form, and I grant the power to act as if I were personally present.

VI.	ATTORNEY-IN-FACT - 	                                    , residing at
Name  of Attorney-in-Fact

Street Address  of Attorney-in-Fact

City of  	        , State of 	                   grant
City of Attorney-in-Fact	State of Attorney-in-Fact
the Attorney-in-Fact the legal authority for a specific financial act on my behalf that can be any power legal under law in the State of

 	. The Specific financial act I grant my Attorney-in-
State
Fact is:

A Detailed Description of Exact Powers granted

VII.	SUCCESSOR ATTORNEY-IN-FACT (Optional) – If the Attorney-in-Fact named above cannot or is

unwilling to serve, then I appoint residing at:

,
Name of Successor Attorney-in-Fact

Street Address of Successor Attorney-in-Fact

City of  	                         , State of  	                             grant
City of Successor Attorney-in-Fact		State of Successor Attorney-in-Fact
the Attorney-in-Fact the legal authority for a specific financial act on my behalf that can be any power legal under law in the State of

 	. The Specific financial act I grant my Successor
State
Attorney-in-Fact is:

A Detailed Description of Exact Powers granted

VIII.	TERMS & CONDITIONS – Upon authorization by all parties, the Attorney-in- Fact accepts their designation to act in the Principal’s best interests for all financial decisions legal under law.
IX.	THIRD PARTIES – I, the Principal, agree that any third party receiving a copy via: physical copy, email, or fax that I, the Principal, will indemnify and hold harmless any and all claims that may be put forth in reference to this Limited Power of Attorney Form.
X.	COMPENSATION – The Attorney-in-Fact agrees not to be compensated for acting in the presence of the Principal. The Attorney-in-Fact may be, but not entitled to, reimbursement for all: food, travel, and lodging expenses for acting in the presence of the Principal.
XI.	DISCLOSURE - I intend for my attorney-in-fact under this Power of Attorney to be treated, as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (aka HIPAA), 42 USC
1320d and 45 CFR 160-164

XII.	PRINCIPAL’S SIGNATURE - I, 	, the Principal, sign my name
Printed Name of Principal
to this power of attorney this 	day of 	, 	and, being first duly sworn, do declare to the undersigned authority that I sign and execute this instrument as my power of attorney and that I sign it willingly, or willingly direct another to sign for me, that I execute it as my free and voluntary act for the purposes expressed in the power of attorney and that I am eighteen years of age or older, of sound mind and under no constraint or undue influence.

Signature of Principal

Notary Acknowledgement (Must be completed by Notary)

State of	
County of  			
Subscribed, Sworn and acknowledged before me by	 	

, the Principal, and subscribed and

sworn to before me by			, witness, this 	day of	,	.

Notary Signature

Notary Public
In and for the County of 	State of   	            My commission expires: 		Seal

XIII.	ATTORNEY-IN-FACT’S SIGNATURE - I,  	
Name of Attorney-in-Fact
have read the attached power of attorney and am the person identified as the attorney-in-fact for the principal. I hereby acknowledge and accept my appointment as Attorney-in-Fact and that when I act as agent I shall exercise the powers for the benefit of the principal; I shall keep the assets of the principal separate from my assets; I shall exercise reasonable caution and prudence; and I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal.

Signature of Attorney-in-Fact	Date

Notary Acknowledgement (Must be completed by Notary)

State of	 	 County of  			
Subscribed, Sworn and acknowledged before me by	 	

, the Principal, and subscribed and

sworn to before me by	 		, witness, this 	day of	,	.

Notary Signature

Notary Public
In and for the County of 	State of   	            My commission expires: 		Seal