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Special Power of Attorney to Sign Checks Form

_____________________, referred to as PRINCIPAL, appoints ___________________, referred to as ATTORNEY, to be my lawful Attorney for me and in my place, to ask, demand, levy, require, and to sign and endorse checks, drafts, bills and notes in my name and in my stead and to be a lawful signatory on any account in my name in any bank or trust company including but not limited to my account at _____________, account and to conduct such other banking transactions as may be possible under the rules of any such bank. The expiration date for this power shall be ___________.

Dated: __________.

___________________________

STATE OF: ___________.

COUNTY OF: __________.

Sworn to and subscribed before me on ____________________.

_______________________________

Notary Public

My commission expires: _______________