DURABLE POWER OF ATTORNEY
OF
__________________________________
THE POWERS GRANTED FROM THE PRINCIPAL TO THE AGENT OR AGENTS IN
THE FOLLOWING DOCUMENT ARE VERY BROAD. THEY MAY INCLUDE THE
POWER TO DISPOSE, SELL, CONVEY AND ENCUMBER YOUR REAL AND
PERSONAL PROPERTY, AND THE POWER TO MAKE YOUR HEALTH CARE
DECISIONS. ACCORDINGLY, THE FOLLOWING DOCUMENT SHOULD ONLY BE
USED AFTER CAREFUL CONSIDERATION. IF YOU HAVE ANY QUESTIONS
ABOUT THIS DOCUMENT, YOU SHOULD SEEK COMPETENT ADVICE.
YOU MAY REVOKE THIS POWER OF ATTORNEY AT ANY TIME
Pursuant to A.S. 13.26.338 - 13.26-353, I, CLIENT of ADDRESS, do
hereby appoint ______________, as my attorney-in-fact to act as
I have checked below, 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
A.S. 13.26.344, to the full extent that I am permitted by law to
act through an agent:
THE AGENT OR AGENTS YOU HAVE APPOINTED WILL HAVE ALL THE POWERS
LISTED BELOW UNLESS YOU DRAW A LINE THROUGH A CATEGORY, AND
INITIAL THE BOX OPPOSITE THAT CATEGORY.
(a) Real Estate Transactions ( )
(b) Transactions involving tangible personal property,
chattels and goods. ( )
(c) Bonds, share and commodities transactions ( )
(d) Banking transactions ( )
(e) Business operating transactions ( )
(f) Insurance transactions ( )
(g) Estate transactions ( )
(h) Gift transactions ( )
(i) Claims and litigation ( )
(j) Personal relationships and affairs ( )
(k) Benefits from government programs and
military service ( )
(l) Health care services ( )
(m) Records, reports and statements ( )
(n) Delegation ( )
(o) I hereby authorize the agent to transfer
into my trust any of my assets, and also
the power to give gifts to myself or otherwise. ( )
(p) All other matters, including those specified as
follows: ( )
IF YOU HAVE APPOINTED MORE THAN ONE AGENT, CHECK ONE OF
THE FOLLOWING:
( ) Each agent may exercise the powers conferred
separately, without the consent of any other agent.
( ) All agents shall exercise the powers conferred jointly
with the consent of all other agents.
TO INDICATE WHEN THIS DOCUMENT SHALL BECOME EFFECTIVE,
CHECK ONE OF THE FOLLOWING:
( ) This document shall become effective upon the date of
my signature.
( ) This document shall become effective upon the date of
my disability and shall not otherwise be affected by my
disability.
IF YOU HAVE INDICATED THAT THIS DOCUMENT SHALL BECOME
EFFECTIVE ON THE DATE OF YOUR SIGNATURE, CHECK ONE OF
THE FOLLOWING:
( ) This document shall not be affected by my subsequent
disability.
( ) This document shall be revoked by my subsequent
disability.
IF YOU HAVE INDICATED THAT THIS DOCUMENT SHALL BECOME
EFFECTIVE UPON THE DATE OF YOUR SIGNATURE AND YOU WANT
TO LIMIT THE TERMS OF THIS DOCUMENT, COMPLETE THE
FOLLOWING:
( ) This document shall only continue in effect for
years from the date of my signature.
NOTICE OF REVOCATION OF THE POWERS
GRANTED IN THIS DOCUMENT.
You may revoke one or more of the powers granted in
this document. Unless otherwise provided in this
document, you may revoke a specific power granted in
this Power Of Attorney by completing a Special Power Of
Attorney that includes the specific Power Of Attorney
that includes the specific power in this document that
you want to revoke. Unless otherwise provided in this
document, you may revoke all the powers granted in this
Power Of Attorney by completing a subsequent Power Of
Attorney.
NOTICE TO THIRD PARTIES
A third party who relies on the reasonable
representations of an attorney-in-fact as to a matter
relating to a power granted by a properly executed
statutory Power Of Attorney does not incur any
liability to the principal or to the principal's heirs,
assigns or estate as a result of permitting the
attorney-in-fact to exercise the authority granted by
the power of attorney. A third party who fails to
honor a properly executed statutory form Power Of
Attorney may be liable to the principal, the attorney-
in-fact, the principal's heirs, assigns or estate for
a civil penalty, plus damages, costs and fees
associated with the failure to comply with the
statutory power of Attorney. If the Power Of Attorney
is one which becomes effective upon the disability of
the principal, the disability of the principal is
established by an affidavit, as required by law.
(The Following Optional Provisions May Appear)
(1) IF YOU HAVE GIVEN THE AGENT AUTHORITY
REGARDING HEALTH CARE SERVICES UNDER
SUBDIVISION L, COMPLETE THE FOLLOWING:
( ) I have executed a separate declaration under Alaska
Statutes 18.12, known as a "Living Will".
( ) I have not executed a "Living Will".
( ) I have executed a separate declaration under AS
47.30.950 - 47.30.980 regarding mental health
treatment. If I have appointed an attorney-in-fact
under AS 47.30.950 - 47.30.980, I authorize that
attorney-in-fact and the attorney-in-fact whom I have
appointed in this document to serve
( ) jointly with consent of each other as to my
mental health treatment
( ) separately without each other's consent as
to my mental health treatment.
( ) I have executed a separate declaration under AS
47.30.950 - 47.30.980.
(2) YOU MAY DESIGNATE AN ALTERNATE ATTORNEY-IN-
FACT. ANY ALTERNATE YOU DESIGNATE WILL BE
ABLE TO EXERCISE THE SAME POWERS AS THE
AGENT(S) YOU NAMED AT THE BEGINNING OF THIS
DOCUMENT. IF YOU WISH TO DESIGNATE AN
ALTERNATE OR ALTERNATES, COMPLETE THE
FOLLOWING:
If the agent(s) named at the beginning of this document is
unable or unwilling to serve or continue to serve, then I appoint
the following agent to serve with the same powers:
First Alternate Or Successor Attorney-In-Fact:
NAME __________________________________
ADDRESS _______________________________
Second Alternate Or Successor Attorney-In-Fact:
NAME & ADDRESS __________________________________
(3) YOU MAY NOMINATE A GUARDIAN OR CONSERVATOR.
IF YOU WISH TO NOMINATE A GUARDIAN OR
CONSERVATOR, COMPLETE THE FOLLOWING:
In the event that a court decides that it is necessary to
appoint a guardian or conservator for me, I hereby nominate
NAME & ADDRESS, to be considered by the court for appointment to
serve as my guardian or conservator, or any similar
representative capacity. In the event she is unable or unwilling
to act, then I nominate NAME & ADDRESS, to serve as my guardian
or conservator, or any similar representative capacity.
IN WITNESS WHEREOF, I have hereunto signed this ___________ day
of ___________ 2001, at Fairbanks, Alaska.
__________________________________
CLIENT
I, _______________, being first duly sworn, depose and state:
I am the person above named; I have read the foregoing
Durable Power Of Attorney and understand the contents thereof and
I have executed the foregoing freely and voluntarily for the
purposes set forth therein.
_____________________________________
CLIENT
SUBSCRIBED, SWORN and ACKNOWLEDGED before me this ______ day
of ___________ 2001, at Fairbanks, Alaska.
__________________________________
NOTARY PUBLIC IN AND FOR ALASKA
My Commission Expires:_____________
Fairbanks Recording District
Upon Recording Return To:
Valerie M. Therrien
779 8th Avenue
Fairbanks, Alaska 99701
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