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New York Statutory Short Form Power of Attorney

(Gen. Oblig. Law 5-1501 - 10/94)

NOTICE: THIS IS AN IMPORTANT DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS. THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON WHOM YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE POWERS TO PLEDGE, SELL, OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. YOU MAY SPECIFY THAT THESE POWERS WILL EXIST EVEN AFTER YOU BECOME DISABLED, INCAPACITATED, OR INCOMPETENT. THE POWERS THAT YOU GIVE YOUR AGENT ARE EXPLAINED MORE FULLY IN NEW YORK GENERAL OBLIGATIONS LAW, ARTICLE 5, TITLE 15, SECTIONS 5-1502A THROUGH 5-1503, WHICH EXPRESSLY PERMITS THE USE OF ANY OTHER OR DIFFERENT FORM OF POWER OF ATTORNEY DESIRED BY THE PARTIES CONCERNED. THIS DOCUMENT DOES NOT AUTHORIZE ANYONE TO MAKE MEDICAL OR OTHER HEALTH CARE DECISIONS FOR YOU. IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.

Know All Men by These Presents, which are intended to constitute a GENERAL POWER OF ATTORNEY pursuant to Article 5, Title 15 of the New York General Obligations Law: That I ....

(insert name and address of the principal)

do hereby appoint: .... .... .... ....

(If 2 or more persons are to be appointed agents with each agent to be able to act alone without requiring the consent of any other agent appointed in order to act, insert the name and address above of each agent separately appointed and be sure to insert the word "or" between each designation of an agent to show that each agent has complete power to act alone. If 2 or more persons are to be appointed agents to act together and requiring the joint consent of all appointed agents to act with no one agent to be able to act alone, insert the names and addresses above of all agents jointly appointed and be sure to insert the word "and" between every designation of each agent to indicate that all agents listed are required to act together and none can act alone)

my attorney(s)-in-fact TO ACT ....

(If more than one agent is designated and the principal wants each agent alone to be able to exercise the power conferred insert in this blank the word "separately." If more than one agent is designated and the principal wants all of the designated agents together to exercise the power conferred, insert in this blank the word "jointly." The failure to make any insertion in this blank will require the agents to act either separately or jointly, in accordance with the principal's use of the word "or" or the word "and" between every respective designation of such agents above. If the principal's wishes cannot be determined because he or she fails to insert the word "or", "and", "separately", or "jointly" as he or she is asked to do above, the principal will be deemed to require the agents designated above to act jointly.)

in my name, place and stead in any way which I myself could do, if I were personally present, with respect to the following matters as each of them is defined in Title 15 of Article 5 of the New York General Obligations Law to the extent that I am permitted by law to act through an agent:

INITIAL in the opposite box any one or more of the subdivisions as to which the principal WANTS to give the agent authority.

NOTICE: THE PRINCIPAL MUST WRITE HIS OR HER INITIALS IN THE CORRESPONDING BLANK SPACE OF A BOX BELOW WITH RESPECT TO EACH OF THE SUBDIVISIONS (A) THROUGH (N) BELOW FOR WHICH THE PRINCIPAL WANTS TO GIVE THE AGENT(S) AUTHORITY. IF THE BLANK SPACE WITHIN A BOX FOR ANY PARTICULAR SUBDIVISION IS NOT INITIALED, NO AUTHORITY WILL BE GRANTED FOR MATTERS THAT ARE INCLUDED IN THAT SUBDIVISION.

(A) real estate transactions; (.......)
(B) chattel and goods transactions; (.......)
(C) bond, share and commodity transactions; (.......)
(D) banking transactions; (.......)
(E) business operating transactions; (.......)
(F) insurance transactions; (.......)
(G) estate transactions; (.......)
(H) claims and litigation; (.......)
(I) personal relationships and affairs; (.......)
(J) benefits from military service; (.......)
(K) records, reports and statements; (.......)
(L) full and unqualified authority to my
attorney(s)-in-fact to delegate any
or all of the foregoing powers to any
person or persons whom my attorney(s)-
in-fact shall select; (.......)
(M) all other matters; (.......)
(N) if the blank space in the box to the right
is initialed by the principal, this power of
attorney shall not be affected by the subsequent
disability or incompetence of the principal; (.......)

(Special provisions and limitations may be included in the statutory short form power of attorney only if they conform to the requirements of section 5-1503 of the New York General Obligations Law.)

To induce any third party to act hereunder, I hereby agree that any third party receiving a duly executed copy or facsimile of this instrument may act hereunder, and that revocation or termination hereof shall be ineffective as to such third party unless and until actual notice or knowledge of such revocation or termination shall have been received by such third party, and I for myself and for my heirs, executors, legal representatives and assigns, hereby agree to indemnify and hold harmless any such third party from and against any and all claims that may arise against such third party by reason of such third party having relied on the provisions of this instrument.

In Witness Whereof I have hereunto signed my name and affixed my seal this _____ day of (month), 20 .

________________________________ (Seal)
(Signature of Principal)

STATE OF ______, COUNTY OF _______, s.s.:

On October _____ 20 , before me personally came the above-named principal, to me known and known to me to be the individual described in, and who executed the foregoing power of attorney, and duly acknowledged to me that executed the same.

_____________________________________

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