This power of attorney shall be in effect from _______________ to

_________________. However, should I be incapacitated or

incompetent at the time stated for expiration (_________________),

this power shall extend until I am no longer incapacitated.

_____________________________________________________

__________________, As Principal

STATE OF ______________

COUNTY OF _____________

__________________ personally appeared before me and acknowledged

the execution of this power of attorney for the purposes set forth

therein.

Dated: _______________________________

__________________________________________

Notary Public