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Simple (1-Page) Power of Attorney Form

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power of attorney form is a one-page legal document used to give a person the ability to carry out tasks on behalf of someone else. The issuer, known as the principal, can be any legal citizen eighteen or older. The recipient of power is called the attorney-in-fact (or agent) and can be anyone the principal knows and trusts (such as a close friend).

To fit on one page, the form waives many of the optional clauses found in more comprehensive power of attorney forms (such as the durable or general versions).

What’s Included?

The form can be broken into five (5) sections, as follows:

  • Party names – Establishes the names of the principal and agent and the agent’s mailing address.
  • Powers – Conveys what acts the attorney-in-fact will have the authority to carry out.
  • Revocation – Covers how the power of attorney can be terminated (i.e., death, incapacitation, manual revocation, specific date, etc).
  • State law – Identifies the state (and statutes) that govern the power of attorney.
  • Signatures – At a minimum, the principal must sign the form in the presence of a notary public. Some states also require the principal to sign before one (1) or two (2) witnesses, who must also sign and date the form.

Sample

POWER OF ATTORNEY

 

BE IT ACKNOWLEDGED that I, [PRINCIPAL NAME], the “Principal”, do hereby grant a limited and specific power of attorney to [ATTORNEY-IN-FACT NAME], of [ATTORNEY-IN-FACT ADDRESS], as my “Attorney-in-Fact”.

Powers. Said Attorney-in-Fact shall have full power and authority to undertake and perform only the following acts on my behalf:

[LIST POWER(S)].

The authority herein shall include such incidental acts as are reasonably required to carry out and perform the specific authorities granted herein. My Attorney-in-Fact agrees to accept this appointment subject to its terms and agrees to act and perform in said fiduciary capacity consistent with my best interests. This Power of Attorney is effective upon execution.

Revocation. This Power of Attorney shall automatically revoke upon my death or incapacitation and shall revoke upon any of the following circumstances: (initial and check all that apply)

[INITIAL] – When the act(s) designated above have been completed.
[INITIAL] – On [MM/DD/YYYY].
[INITIAL] – Other: [OTHER].

State Law. This Power of Attorney is governed by the laws of the State of [STATE NAME].

Principal’s Signature: ___________________ Signing Date: [MM/DD/YYYY]

 

WITNESS ACKNOWLEDGMENT

Witness 1 Signature: ___________________ Signing Date: [MM/DD/YYYY]

Witness 2 Signature: ___________________ Signing Date: [MM/DD/YYYY]

 

NOTARY ACKNOWLEDGMENT

STATE OF [STATE]
COUNTY OF [COUNTY]

On [MM/DD/YYYY], before me appeared [PRINCIPAL NAME], as Principal of this Power of Attorney, who proved to me through government-issued photo identification to be the above-named person, in my presence executed the foregoing instrument and acknowledged that he executed the same as his free act and deed.
___________________
Notary Public

My commission expires: [MM/DD/YYYY]