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Special Power of Attorney Form

SPECIAL POWER OF ATTORNEYI, [YOUR FULL LEGAL NAME], residing at [YOUR FULL ADDRESS], hereby appoint ____________________ residing at ___________________, as my as my Attorney-in-Fact ("Agent") to act in my capacity to do any and all of the following: (DESCRIBE HERETHE EXTENT OF AUTHORITY YOU ARE GIVING TO YOUR ATTORNEY-IN-FACT) The rights, powers, and authority of my Agent 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20__, and shall remain in full force and effect until ______________, 20__, or unless specifically extended or rescinded earlier by either party. Dated ____________________, 2000 at __________________, _________________________.[YOUR SIGNATURE]
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[YOUR FULL LEGAL NAME]


[WITNESS' SIGNATURE]
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[WITNESS' FULL LEGAL NAME]


[WITNESS' SIGNATURE]
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[WITNESS' FULL LEGAL NAME]
 
STATE OF _____________________ 
 
COUNTY OF ____________________ 
In _______________, on the _____________ day of ____________, 20 __, before me, a Notary Public in and for the above state and county, personally appeared [list name of person revoking power of attorney] , known to me or proved to be the person named in and who executed the foregoing instrument, and being first duly sworn, such person acknowledged that he or she executed said instrument for the purposes therein contained as his or her free and voluntary act and deed.
 
 
              _______________________________ 
                            NOTARY PUBLIC 
                            My Commission Expires: ________