CONNECTICUT MINOR (CHILD) POWER OF ATTORNEY
1. For the Minor named [CHILD’S NAME], born on [MM/DD/YYYY] (hereinafter known as the “Minor”), I, [PARENT’S NAME], the ☐ Parent or ☐ Court Appointed Guardian with a street address of [PARENT’S ADDRESS],

And I, [CO-PARENT’S NAME], the ☐ Parent or ☐ Court Appointed Guardian with a street address of [CO-PARENT’S ADDRESS],

2. Hereby appoint [ATTORNEY-IN-FACT’S NAME] as the Attorney-in-Fact for the Minor who is their [RELATION TO CHILD] with a street address of [ATTORNEY-IN-FACT’S ADDRESS] (hereinafter referred to as the “Attorney-in-Fact”).

3. I/We delegate to the Attorney-in-Fact the authority to [DESCRIBE AUTHORITY].

4. This power of attorney document shall commence on [MM/DD/YYYY] and end on:

A. [INITIAL] ☐ – [MM/DD/YYYY].
B. [INITIAL] ☐ – In the event of my disability (incapacitation).
C. [INITIAL] ☐ – In the event of my death.

This document can be terminated at any time by completing a revocation or by creating a new minor power of attorney form.

5. This power of attorney shall be governed under the laws in the State of Connecticut and terminates any prior written form.

Parent/Guardian Signature: _______________ Date: _______
Print Name: _______________

Parent/Guardian Signature: _______________ Date: _______
Print Name: _______________

ACCEPTANCE BY ATTORNEY-IN-FACT

The undersigned Attorney-in-Fact acknowledges and executes this Power of Attorney, and by such execution does hereby affirm that I: (A) accept the appointment; (B) understand the duties under the Power of Attorney and under the law.

Attorney-in-Fact Signature: _______________ Date: _______
Print Name: _______________

AFFIRMATION BY WITNESSES

I witnessed the execution of this Power of Attorney by the Parent/Court Appointed Guardian(s), and I affirm that the Parent/Court Appointed Guardian(s) appeared to me to be of sound mind, was not under duress, and the Parent/Court Appointed Guardian(s) affirmed to me that he/she was aware of the nature of this Power of Attorney and signed it freely and voluntarily.

Witness Signature: _______________ Date: _______
Print Name: _______________ Address: _______________

Witness Signature: _______________ Date: _______
Print Name: _______________ Address: _______________

NOTARY ACKNOWLEDGMENT

State of Connecticut
County of _______________, ss.

On _______, before me appeared _______________, as the Parent(s)/Court Appointed Guardian(s) who proved to me through government-issued photo identification to be the above-named person(s), who in my presence executed the foregoing instrument and acknowledged that (s)he executed the same as his/her free act and deed.

Notary Signature: _______________
Print Name: _______________
My Commission Expires: _______ (Notary Seal)