Statutory Short Form Power of Attorney with Instructions

STATUTORY SHORT FORM POWER OF ATTORNEY

NOTICE: The powers granted by this document are broad and sweeping. They are defined in Connecticut Statutory Short Form Power of Attorney Act, sections 1-42 through 1-56, inclusive, of the general statutes, 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 attorney-in-fact may make application to a court of probate for an accounting as provided in subsection (b) of Connecticut laws on accounting.

Know all Men by these Presents, which are intended to constitute a GENERAL POWER OF ATTORNEY pursuant to Connecticut Statutory Short Form Power of Attorney Act:

That I, _____________, of ___________, Connecticut, do hereby appoint:
^{(Print your name) (Town)}

[WRITE IN NAME, TOWN, AND STATE OF ONE OR MORE INDIVIDUALS OR CORPORATIONS TO ACT AS YOUR ATTORNEY-IN-FACT; ADD MORE IF NECESSARY; "x" OUT LINES NOT COMPLETED]

____________________________________, of ________________________________,
                    (Name)                       (Town and State)
____________________________________, of ________________________________,
                    (Name)                       (Town and State)
____________________________________, of ________________________________,
                    (Name)                       (Town and State)

as my attorney(s)-in-fact TO ACT:

     CHECK ONE BOX IF APPOINTING MORE THAN ONE ATTORNEY-IN-FACT
     [ ]SEVERALLY (independently
     [ ]JOINTLY (requiring both to consent and sign)

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 Statutory Short Form 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 subdivisions as to which the principal does NOT desire to give the agent authority. Such elimination of any one or more of subdivisions (A) to (L), inclusive, shall automatically constitute an elimination of subdivision (L).)

NOTE: To strike out any subdivisions the principal must draw a line through the text of that subdivision AND write his or her initials in the box opposite. [If you do not draw a line through and initial, you are giving your agent authority to exercise all of the following powers.]

[NOTE: You may insert additional powers here]

Second: with full and unqualified authority to delegate any or all the foregoing powers to any person or persons whom my attorneys-in-fact shall select.

Third: hereby ratifying and confirming all that said attorneys or substitutes do or cause to be done.

     In Witness Whereof, I have hereunto signed my name and affixed my seal this
_______ day of _________________, __________.
(date)                        (month)            (year)

                                         ___________________________ (L.S.)
                                                                  (SIGNATURE)

WITNESSES (one of whom may be the notary, attorney, etc. taking the acknowledgment)

Attested and subscribed in the presence of the
principal and subsequent to the principal
subscribing same:

First Witness signs:_______________________________________________
Print witness name:

Second Witness signs:_______________________________________________
Print witness name:

STATE OF CONNECTICUT   )
                       ) ss: at ____________ on __________   ______, _____
COUNTY OF ____________ )           (Town)                (month)        (day)    (year)

Personally Appeared _________________________, Signer and Sealer of the foregoing instrument, and acknowledged the same to be his/her free act and deed, before me.

                                       ________________________________
                                       Commissioner of the Superior Court
                                       or
                                       Notary Public
                                      (if notary) My commission expires:

INSTRUCTIONS FOR SIGNING
CONNECTICUT POWER OF ATTORNEY

ARRANGE FOR:

TWO ADULT WITNESSES; AND

A NOTARY PUBLIC, CONNECTICUT ATTORNEY, OR: (1) judge of court of record or a family support magistrate; (2) clerk or deputy clerk of a court having a seal; (3) commissioner of deeds or town clerk; or (5) justice of the peace)

TO BE PRESENT DURING THE SIGNING

Your attorney(s)-in-fact may not be one of the witnesses.
The notary or other person taking your “acknowledgment” may be one of the witnesses.
Toward the top of the page, print your name on the line beginning "That I."
Print your town and state of residence after the word "of."
You may name one or more persons to act as your attorney-in-fact, by inserting their names and addresses after the words "do hereby appoint," on the lines provided.
You should "cross out" unused lines.
If you have named more than one attorney-in-fact, CHECK the box for them to act "severally" or "jointly."
There are 14 subdivisions, labeled (A) through (L), which represent the powers which you as principal may confer upon your attorney-in-fact. If you do not wish to confer a particular power upon your attorney-in-fact, draw a line through the text of that subdivision and write your initials in the corresponding brackets.
Insert the date on the line beginning "IN WITNESS WHEREOF."
On the line labeled "L.S.," sign your name and print your name under the line.
Each of TWO witnesses must sign on one of the two lines labeled "Witness," and should print his or her name under the signature.
The notary, Connecticut attorney, etc. should ask you if the document is your "free act and deed," fill in the town and date of signing, fill in your name, sign on the line provided, and write in when his or her commission expires (if a notary). If a notary or clerk with a seal, the seal should be embossed onto the document. If a Connecticut attorney, no seal is required.