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Free Connecticut Statutory Power of Attorney Form - PDF Form Download

Connecticut Statutory Power of Attorney Form Overall rating: 0 out of 5 based on 0 reviews.

Download and use this form in the State of Connecticut to grant someone else the power to make decisions on your behalf.

Connecticut-Statutory-Power-of-Attorney-Form


Text Version of the Form

———————– Page 1———————–
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).)

———————– Page 2———————–

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.]

(A) real estate transactions; [ ]
(B) chattel and goods transactions; [ ]
(C) bond, share and commodity transactions; [ ]
(D) banking transactions [ ]
(E) business operating transactions; [ ]
(F) insurance transactions; [ ]
(G) estate transactions; [ ]
(H) claims and litigation; [ ]
(I) personal relationships and affairs; [ ]
(J) benefits from military service; [ ]
(K) records, reports and statements; [ ]
(L) all other matters; [ ]

[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:

———————– Page 3———————–

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:

———————– Page 4———————–

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.

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