I, ______________________, of ___________________, hereby appoint ___________________________ of
__________________________, as my attorney in fact to act in my capacity to do any and all of the following: (DESCRIBE THE EXTENT OF AUTHORITY YOU ARE GIVING TO YOUR ATTORNEY-IN-FACT)
The rights, powers, and authority of my attorney in fact to exercise any and all of the rights and powers herein granted
shall commence and be in full force and effect on ___________________, 20___, and shall remain in full force and effect until
__________________________ or unless specifically extended or rescinded earlier by either party. Dated _________________________, 20___. __________________________ STATE OF ___________________ COUNTY OF __________________ BEFORE ME, the undersigned authority, on this __ day of _______________, 20__, personally appeared ______________________
to me well known to be the person described in and who signed the Foregoing, and acknowledged to me that he executed the same
freely and voluntarily for the uses and purposes therein expressed. WITNESS my hand and official seal the date aforesaid. ____________________________ My Commission Expires:______
NOTARY PUBLIC
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