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 ___________ 2012, 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 ___________ 2012, at Fairbanks, Alaska. __________________________________ NOTARY PUBLIC IN AND FOR ALASKA My Commission Expires:_____________ Fairbanks Recording District Upon Recording Return To: Valerie M. Therrien Attorney-at-Law, P.C. 529 5th Avenue Suite 300 Fairbanks, Alaska 99701-4717