Text Version of this Form
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THE POWERS YOU GRANT BELOW ARE EFFECTIVE
ONLY IF YOU BECOME DISABLED OR INCOMPETENT
NOTICE: THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD AND SWEEPING.
THEY ARE EXPLAINED IN THE UNIFORM STATUTORY FORM POWER OF ATTORNEY ACT.
IF YOU HAVE ANY QUESTIONS ABOUT THESE POWERS, OBTAIN COMPETENT LEGAL
ADVICE. THIS DOCUMENT DOES NOT AUTHORIZE ANYONE TO MAKE MEDICAL AND
OTHER HEALTH-CARE DECISIONS FOR YOU. YOU MAY REVOKE THIS POWER OF
ATTORNEY IF YOU LATER WISH TO DO SO.
_____________________________________________ [insert your name and address] appoint
_____________________________________________ [insert the name and address of the
person appointed] as my Agent (attorney-in-fact) to act for me in any lawful way with respect to
the following initialed subjects:
TO GRANT ALL OF THE FOLLOWING POWERS, INITIAL THE LINE IN FRONT OF (N) AND
IGNORE THE LINES IN FRONT OF THE OTHER POWERS.
TO GRANT ONE OR MORE, BUT FEWER THAN ALL, OF THE FOLLOWING POWERS,
INITIAL THE LINE IN FRONT OF EACH POWER YOU ARE GRANTING.
TO WITHHOLD A POWER, DO NOT INITIAL THE LINE IN FRONT OF IT. YOU MAY, BUT
NEED NOT, CROSS OUT EACH POWER WITHHELD.
Note: If you initial Item A or Item B, which follow, a notarized signature will be required on
behalf of the Principal.
_______ (A) Real property transactions. To lease, sell, mortgage, purchase, exchange, and
acquire, and to agree, bargain, and contract for the lease, sale, purchase, exchange, and
acquisition of, and to accept, take, receive, and possess any interest in real property whatsoever,
on such terms and conditions, and under such covenants, as my Agent shall deem proper; and to
maintain, repair, tear down, alter, rebuild, improve manage, insure, move, rent, lease, sell,
convey, subject to liens, mortgages, and security deeds, and in any way or manner deal with all
or any part of any interest in real property whatsoever, including specifically, but without limitation,
real property lying and being situated in the State of Ohio, under such terms and conditions, and
under such covenants, as my Agent shall deem proper and may for all deferred payments accept
purchase money notes payable to me and secured by mortgages or deeds to secure debt, and
may from time to time collect and cancel any of said notes, mortgages, security interests, or
deeds to secure debt.
_______ (B) Tangible personal property transactions. To lease, sell, mortgage, purchase,
exchange, and acquire, and to agree, bargain, and contract for the lease, sale, purchase,
exchange, and acquisition of, and to accept, take, receive, and possess any personal property
whatsoever, tangible or intangible, or interest thereto, on such terms and conditions, and under
such covenants, as my Agent shall deem proper; and to maintain, repair, improve, manage,
insure, rent, lease, sell, convey, subject to liens or mortgages, or to take any other security
interests in said property which are recognized under the Uniform Commercial Code as adopted
at that time under the laws of the State of Ohio or any applicable state, or otherwise hypothecate
(pledge), and in any way or manner deal with all or any part of any real or personal property
whatsoever, tangible or intangible, or any interest therein, that I own at the time of execution or
may thereafter acquire, under such terms and conditions, and under such covenants, as my
Agent shall deem proper.
_______ (C) Stock and bond transactions. To purchase, sell, exchange, surrender, assign,
redeem, vote at any meeting, or otherwise transfer any and all shares of stock, bonds, or other
securities in any business, association, corporation, partnership, or other legal entity, whether
private or public, now or hereafter belonging to me.
_______ (D) Commodity and option transactions. To buy, sell, exchange, assign, convey,
settle and exercise commodities futures contracts and call and put options on stocks and stock
indices traded on a regulated options exchange and collect and receipt for all proceeds of any
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such transactions; establish or continue option accounts for the principal with any securities or
futures broker; and, in general, exercise all powers with respect to commodities and options
which the principal could if present and under no disability.
_______ (E) Banking and other financial institution transactions. To make, receive, sign,
endorse, execute, acknowledge, deliver and possess checks, drafts, bills of exchange, letters of
credit, notes, stock certificates, withdrawal receipts and deposit instruments relating to accounts
or deposits in, or certificates of deposit of banks, savings and loans, credit unions, or other
institutions or associations. To pay all sums of money, at any time or times, that may hereafter
be owing by me upon any account, bill of exchange, check, draft, purchase, contract, note, or
trade acceptance made, executed, endorsed, accepted, and delivered by me or for me in my
name, by my Agent. To borrow from time to time such sums of money as my Agent may deem
proper and execute promissory notes, security deeds or agreements, financing statements, or
other security instruments in such form as the lender may request and renew said notes and
security instruments from time to time in whole or in part. To have free access at any time or
times to any safe deposit box or vault to which I might have access.
_______ (F) Business operating transactions. To conduct, engage in, and otherwise transact
the affairs of any and all lawful business ventures of whatever nature or kind that I may now or
hereafter be involved in. To organize or continue and conduct any business which term includes,
without limitation, any farming, manufacturing, service, mining, retailing or other type of business
operation in any form, whether as a proprietorship, joint venture, partnership, corporation, trust or
other legal entity; operate, buy, sell, expand, contract, terminate or liquidate any business; direct,
control, supervise, manage or participate in the operation of any business and engage,
compensate and discharge business managers, employees, agents, attorneys, accountants and
consultants; and, in general, exercise all powers with respect to business interests and operations
which the principal could if present and under no disability.
_______ (G) Insurance and annuity transactions. To exercise or perform any act, power, duty,
right, or obligation, in regard to any contract of life, accident, health, disability, liability, or other
type of insurance or any combination of insurance; and to procure new or additional contracts of
insurance for me and to designate the beneficiary of same; provided, however, that my Agent
cannot designate himself or herself as beneficiary of any such insurance contracts.
_______ (H) Estate, trust, and other beneficiary transactions. To accept, receipt for,
exercise, release, reject, renounce, assign, disclaim, demand, sue for, claim and recover any
legacy, bequest, devise, gift or other property interest or payment due or payable to or for the
principal; assert any interest in and exercise any power over any trust, estate or property subject
to fiduciary control; establish a revocable trust solely for the benefit of the principal that terminates
at the death of the principal and is then distributable to the legal representative of the estate of
the principal; and, in general, exercise all powers with respect to estates and trusts which the
principal could exercise if present and under no disability; provided, however, that the Agent may
not make or change a will and may not revoke or amend a trust revocable or amendable by the
principal or require the trustee of any trust for the benefit of the principal to pay income or
principal to the Agent unless specific authority to that end is given.
_______ (I) Claims and litigation. To commence, prosecute, discontinue, or defend all actions
or other legal proceedings touching my property, real or personal, or any part thereof, or touching
any matter in which I or my property, real or personal, may be in any way concerned. To defend,
settle, adjust, make allowances, compound, submit to arbitration, and compromise all accounts,
reckonings, claims, and demands whatsoever that now are, or hereafter shall be, pending
between me and any person, firm, corporation, or other legal entity, in such manner and in all
respects as my Agent shall deem proper.
_______ (J) Personal and family maintenance. To hire accountants, attorneys at law,
consultants, clerks, physicians, nurses, agents, servants, workmen, and others and to remove
them, and to appoint others in their place, and to pay and allow the persons so employed such
salaries, wages, or other remunerations, as my Agent shall deem proper.
_______ (K) Benefits from Social Security, Medicare, Medicaid, or other governmental
programs, or military service. To prepare, sign and file any claim or application for Social
Security, unemployment or military service benefits; sue for, settle or abandon any claims to any
benefit or assistance under any federal, state, local or foreign statute or regulation; control,
deposit to any account, collect, receipt for, and take title to and hold all benefits under any Social
Security, unemployment, military service or other state, federal, local or foreign statute or
regulation; and, in general, exercise all powers with respect to Social Security, unemployment,
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military service, and governmental benefits, including but not limited to Medicare and Medicaid,
which the principal could exercise if present and under no disability.
_______ (L) Retirement plan transactions. To contribute to, withdraw from and deposit funds
in any type of retirement plan (which term includes, without limitation, any tax qualified or
nonqualified pension, profit sharing, stock bonus, employee savings and other retirement plan,
individual retirement account, deferred compensation plan and any other type of employee
benefit plan); select and change payment options for the principal under any retirement plan;
make rollover contributions from any retirement plan to other retirement plans or individual
retirement accounts; exercise all investment powers available under any type of self-directed
retirement plan; and, in general, exercise all powers with respect to retirement plans and
retirement plan account balances which the principal could if present and under no disability.
_______ (M) Tax matters. To prepare, to make elections, to execute and to file all tax, social
security, unemployment insurance, and informational returns required by the laws of the United
States, or of any state or subdivision thereof, or of any foreign government; to prepare, to
execute, and to file all other papers and instruments which the Agent shall think to be desirable or
necessary for safeguarding of me against excess or illegal taxation or against penalties imposed
for claimed violation of any law or other governmental regulation; and to pay, to compromise, or
to contest or to apply for refunds in connection with any taxes or assessments for which I am or
may be liable.
_______ (N) ALL OF THE POWERS LISTED ABOVE. YOU NEED NOT INITIAL ANY OTHER
LINES IF YOU INITIAL LINE (N).
ON THE FOLLOWING LINES YOU MAY GIVE SPECIAL INSTRUCTIONS LIMITING OR
EXTENDING THE POWERS GRANTED TO YOUR AGENT.
THIS POWER OF ATTORNEY SHALL BE CONSTRUED AS A GENERAL DURABLE POWER
THIS POWER OF ATTORNEY BECOMES EFFECTIVE ONLY UPON MY DISABILITY OR
INCAPACITY. I shall be considered disabled or incapacitated for purposes of this power of
attorney if a physician certifies in writing at a date later than the date this power of attorney is
executed that, based on the physician’s medical examination of me, I am mentally incapable of
managing my financial affairs. I authorize the physician who examines me for this purpose to
disclose my physical or mental condition to another person for purposes of this power of attorney.
A third party who accepts this power of attorney is fully protected from any action taken under this
power of attorney that is based on the determination made by a physician of my disability or
(YOUR AGENT WILL HAVE AUTHORITY TO EMPLOY OTHER PERSONS AS NECESSARY
TO ENABLE THE AGENT TO PROPERLY EXERCISE THE POWERS GRANTED IN THIS
FORM, BUT YOUR AGENT WILL HAVE TO MAKE ALL DISCRETIONARY DECISIONS. IF YOU
WANT TO GIVE YOUR AGENT THE RIGHT TO DELEGATE DISCRETIONARY DECISION-
MAKING POWERS TO OTHERS, YOU SHOULD KEEP THE NEXT SENTENCE, OTHERWISE
IT SHOULD BE STRICKEN.)
Authority to Delegate. My Agent shall have the right by written instrument to delegate any or all
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of the foregoing powers involving discretionary decision-making to any person or persons whom
my Agent may select, but such delegation may be amended or revoked by any agent (including
any successor) named by me who is acting under this power of attorney at the time of reference.
(YOUR AGENT WILL BE ENTITLED TO REIMBURSEMENT FOR ALL REASONABLE
EXPENSES INCURRED IN ACTING UNDER THIS POWER OF ATTORNEY. STRIKE OUT THE
NEXT SENTENCE IF YOU DO NOT WANT YOUR AGENT TO ALSO BE ENTITLED TO
REASONABLE COMPENSATION FOR SERVICES AS AGENT.)
Right to Compensation. My Agent shall be entitled to reasonable compensation for services
rendered as agent under this power of attorney.
(IF YOU WISH TO NAME SUCCESSOR AGENTS, INSERT THE NAME(S) AND ADDRESS(ES)
OF SUCH SUCCESSOR(S) IN THE FOLLOWING PARAGRAPH.)
Successor Agent. If any Agent named by me shall die, become incompetent, resign or refuse to
accept the office of Agent, I name the following (each to act alone and successively, in the order
named) as successor(s) to such Agent:
Choice of Law. THIS POWER OF ATTORNEY WILL BE GOVERNED BY THE LAWS OF THE
STATE OF OHIO WITHOUT REGARD FOR CONFLICTS OF LAWS PRINCIPLES. IT WAS
EXECUTED IN THE STATE OF OHIO AND IS INTENDED TO BE VALID IN ALL
JURISDICTIONS OF THE UNITED STATES OF AMERICA AND ALL FOREIGN NATIONS.
I am fully informed as to all the contents of this form and understand the full import of this grant of
powers to my Agent.
I agree that any third party who receives a copy of this document may act under it. Revocation of
the power of attorney is not effective as to a third party until the third party learns of the
revocation. I agree to indemnify the third party for any claims that arise against the third party
because of reliance on this power of attorney.
Signed this _______ day of _______________, 20____
CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC
STATE OF OHIO
COUNTY OF ________________
This document was acknowledged before me on _______________ [Date] by
________________________________________________ [name of principal].
[Notary Seal, if any]:
(Signature of Notarial Officer)
Notary Public for the State of Ohio
My commission expires: ___________________
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ACKNOWLEDGMENT OF AGENT
BY ACCEPTING OR ACTING UNDER THE APPOINTMENT, THE AGENT ASSUMES THE
FIDUCIARY AND OTHER LEGAL RESPONSIBILITIES OF AN AGENT.
[Typed or Printed Name of Agent]
[Signature of Agent]
This document was prepared by the following individual:
[Typed or Printed Name]