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  1.  
  2. "POWER OF ATTORNEY
  3. "
  4. "I, \a, residing at:
  5. "
  6. "\b
  7. "\c
  8. "\d
  9. "
  10. "hereby appoint \e, residing at:
  11. "
  12. "\f
  13. "\g
  14. "\h
  15. "
  16. "as my Attorney-in-Fact, hereinafter referred to as 'Agent'.
  17. "My Agent shall have full power and authority to act on my behalf, but
  18. "only to the extent permitted by this Special Power of Attorney.  My
  19. "Agent's power(s) shall include the power(s) to:
  20. "
  21. "\i
  22. "\j
  23. "\k
  24. "\l
  25. "
  26. "I hereby grant to my Agent the full right, power, and authority to do
  27. "every act, deed, and thing necessary or advisable to be done regarding
  28. "the above power(s), as fully as I could do if personally present and
  29. "acting.
  30. "
  31. "My Agent shall not be liable for any loss that results from a faith.
  32. "However, my Agent shall be liable for willful misconduct or the
  33. "failure to act in good faith while acting under the authority of this
  34. "Power of Attorney.
  35. "
  36. "My Agent shall not be entitled to any compensation, during my lifetime
  37. "or upon my death, for any services provided as my Agent.  My Agent,
  38. "however, shall be entitled to reimbursement of all reasonable expenses
  39. "incurred in connection with this Power of Attorney.
  40. "
  41. "This Power of Attorney shall become effective immediately, shall not
  42. "be affected by my disability or lack of mental competence, and shall
  43. "continue in effect until my death; provided, however, that this Power
  44. "of Attorney may be revoked by me at any time by providing written
  45. "notice to my Agent.
  46. "
  47. "Signed on this {CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@} day of {CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}, {CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}.
  48. "
  49. "
  50. "
  51. "
  52. "{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}
  53. "(grantor of Power of Attorney)
  54. "
  55. "
  56. "
  57. "
  58. "
  59. "STATE/COMMONWEALTH OF {CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}
  60. "COUNTY/BOROUGH/PARISH OF {CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}
  61. "
  62. "BEFORE ME, the undersigned authority, on this day personally appeared
  63. "{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@} [name(s)], known to me
  64. "to be the person(s) whose name(s) is(are) subscribed to the foregoing
  65. "instrument, and acknowledged to me that he(she)(they) executed said
  66. "instrument for the purposes and consideration therein expressed.
  67. "
  68. "GIVEN under my hand and seal of office on this {CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@} day of
  69. "{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}, {CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}.
  70. "
  71. "
  72. "
  73. "{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}
  74. "Notary Public's Signature
  75. "
  76. "(seal/stamp)
  77. "
  78. "
  79. "
  80.