DURABLE GENERAL POWER OF ATTORNEY EFFECTIVE AT A FUTURE TIME
NEW YORK STATUTORY SHORT FORM

(CAUTION: THIS IS AN IMPORTANT DOCUMENT. IT GIVES THE PERSON WHOM YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY DURING YOUR LIFETIME, WHICH MAY INCLUDE POWERS TO MORTGAGE, SELL, OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THESE POWERS MAY ONLY BE USED AFTER A CERTIFICATION THAT YOU HAVE BECOME DISABLED, INCAPACITATED, OR INCOMPETENT OR THAT SOME OTHER EVENT HAS OCCURRED. THESE POWERS ARE EXPLAINED MORE FULLY IN NEW YORK GENERAL OBLIGATIONS LAW, ARTICLE 5, TITLE 15, SECTIONS 5-1502A THROUGH 5-1506, WHICH EXPRESSLY PERMITS THE USE OF ANY OTHER OR DIFFERENT FORM OF POWER OF ATTORNEY.

THIS DOCUMENT DOES NOT AUTHORIZE ANYONE TO MAKE MEDICAL OR OTHER HEALTH CARE DECISIONS. YOU MAY EXECUTE A HEALTH CARE PROXY TO DO THIS.

IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.)

THIS is intended to constitute a POWER OF ATTORNEY EFFECTIVE AT A FUTURE TIME pursuant to Article 5, Title 15 of the New York General Obligations Law:

I, _________________________________________________________________
_________________________________________________________________
(insert your name and address)

do hereby appoint:
_________________________________________________________________

(If 1 person is to be appointed agent, insert the name and address of your agent above)
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
(If 2 or more persons are to be appointed agents by you, insert their names and addresses above)

my attorney(s)-in-fact TO ACT

(If more than one agent is designated, CHOOSE ONE of the following two choices by putting your initials in ONE of the blank spaces

(            ) to the left of your choice:)
(            ) Each agent may SEPARATELY act.
(            ) All agents must act TOGETHER.
(If neither blank space is initialed, the agents will be required to act TOGETHER)

TO TAKE EFFECT upon the occasion of the signing of a written statement EITHER:

(INSTRUCTIONS: COMPLETE OR OMIT SECTION (I) --OR-- SECTION (II) BELOW BUT NEVER COMPLETE BOTH SECTIONS (I) AND (II) BELOW. IF YOU DO NOT COMPLETE EITHER SECTION (I) OR SECTION (II) BELOW, IT SHALL BE PRESUMED THAT YOU WANT THE PROVISIONS OF SECTION (I) BELOW TO APPLY)

(I) by a physician or physicians named herein by me at this point:
Dr. ______________________________________________________________
_________________________________________________________________
_________________________________________________________________
(Insert Full Name(s) and Address(es) of Certifying Physician(s) Chosen by You)

or if no physician or physicians are named hereinabove, or if the physician or physicians named hereinabove are unable to act, by my regular physician, or by a physician who has treated me within one year preced- ing the date of such signing, or by a licensed psychologist or psychia- trist, certifying that I am suffering from diminished capacity that would preclude me from conducting my affairs in a competent manner;

--OR--

(II) by a person or persons named herein by me at this point:
_________________________________________________________________
_________________________________________________________________
(Insert Full Name(s) and Address(es) of Certifying Person(s) Chosen by You)

CERTIFYING that the following specified event has occurred:
_________________________________________________________________
_________________________________________________________________
(Insert hereinabove the specified event the certification of which

will cause THIS POWER OF ATTORNEY to take effect)

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:

(DIRECTIONS: Initial in the blank space to the left of your choice any one or more of the following lettered subdivisions as to which you WANT to give your agent authority. If the blank space to the left of any particular lettered subdivision is NOT initialed, NO AUTHORITY WILL BE GRANTED for matters that are included in that subdivision. Alternatively, the letter corresponding to each power you wish to grant may be written or typed on the blank line in subdivision "(Q)", and you may then put your initials in the blank space to the left of subdivision "(Q)" in order to grant each of the powers so indicated)

(            ) (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) retirement benefit transactions;
(            ) (M) making gifts to my spouse, children and more remote descendants, and parents, not to exceed in the aggregate $10,000 to each of such persons in any year;
(            ) (N) tax matters;
(            ) (O) all other matters;
(            ) (P) 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;
(            ) (Q) each of the above matters identified by the following letters:
_________________________________________________________________

This durable Power of Attorney shall not be affected by my subsequent disability or incompetence.

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

If every agent named above is unable or unwilling to serve, I appoint

_________________________________________________________________
(insert name and address of successor)

to be my agent for all purposes hereunder.

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 TOGETHER WITH A DULY EXECUTED COPY OR FACSIMILE OF THE WRITTEN STATEMENT OR STATEMENTS OF CERTIFICATION REQUIRED FOR THIS INSTRUMENT TO BE EFFECTIVE MAY ACT HEREUNDER, AND THAT THE SUSPENSION, REVOCATION OR TERMINATION HEREOF SHALL BE INEFFECTIVE AS TO SUCH THIRD PARTY UNLESS AND UNTIL ACTUAL NOTICE OR KNOWLEDGE OF SUCH SUSPENSION, 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.

THIS GENERAL POWER OF ATTORNEY EFFECTIVE AT A FUTURE TIME MAY BE REVOKED BY ME AT ANY TIME.

In Witness Whereof I have hereunto signed my name this _____ day of ______________________, 20_____.

(YOU SIGN HERE:) ==>     __________________________________
(Signature of Principal)

ACKNOWLEDGEMENT

STATE OF NEW YORK
COUNTY OF __________________

On this ____ day of __________________, 20_____ before me the undersigned, personally appeared ,__________________________________, personally known to be or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity, and that by his signature on the instrument, the individual, or the person who acted on behalf of the individual, executed the instrument and that such individual made such appearance before the undersigned in the City of __________________, County of __________________, State of New York.

__________________________________
Notary



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