A document substantially in the following form may be used to create a statutory form power of attorney that has the meaning and effect prescribed by the Nebraska Uniform Power of Attorney Act.

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NEBRASKA

STATUTORY FORM POWER OF ATTORNEY

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 the Nebraska 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.

This form will not revoke a power of attorney previously executed by you unless you add that the previous power of attorney is revoked or that all other powers of attorney are revoked by this power of attorney.

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: …………..

Release of Information

I agree to, authorize, and allow full release of information, by any governmental agency, business, creditor, or third party who may have information pertaining to my assets or income, to my agent named herein.

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 the Nebraska 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 the Nebraska 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

(…..) Delegate to 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

(…..) Renounce or disclaim an interest in property, including a power of appointment

LIMITATION ON AGENT’S AUTHORITY

Except as otherwise authorized by the Power of Personal and Family Maintenance, an agent 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 or the Grant of Specific Authority.

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 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:
……………………………………….
………………………………………]

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