Sample Statutory Short Form Durable Power of Attorney

Connecticut Statutory Short Form Durable Power of Attorney


NOTICE: The powers granted by this document are broad and sweeping. They are defined in Connecticut Statutory Short Form Power of Attorney Act, sections 1-42 to 1-56, inclusive, of the general statutes, which expressly permits the use of any other or different form of power of attorney desired by the parties concerned. The grantor of any power of attorney or the attorney-in-fact may make application to a court of probate for an accounting as provided in subsection (b) of section 45a-175. 

Know All Men by These Presents, which are intended to constitute a GENERAL POWER OF ATTORNEY pursuant to Connecticut Statutory Short Form Power of Attorney Act: 


That I ________________________________________________________________ (insert name and address of the principal) do hereby appoint _____________________________________________________________________ (insert name and address of the agent, or each agent, if more than one is designated) my attorney(s)- in-fact TO ACT _________________ 


If more than one agent is designated and the principal wishes each agent alone to be able to exercise the power conferred, insert in this blank the word "severally". Failure to make any insertion or the insertion of the word "jointly" shall require the agents to act jointly. 


First: 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 the Connecticut Statutory Short Form Power of Attorney Act to the extent that I am permitted by law to act through an agent: 


(Strike out and initial in the opposite box any one or more of the subdivisions as to which the principal does NOT desire to give the agent authority. Such elimination of any one or more of subdivisions (A) to (L), inclusive, shall automatically constitute an elimination also of subdivision (M).) 

To strike out any subdivision the principal must draw a line through the text of that subdivision AND write his initials in the box opposite. 


(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) health care decisions; (______) 

(M) all other matters; (_____) 


___________________________________________________________________ 

___________________________________________________________________ 

___________________________________________________________________ 

___________________________________________________________________ 


(Special provisions and limitations may be included in the statutory short form power of attorney only if they conform to the requirements of the Connecticut Statutory Short Form Power of Attorney Act.) 


Second: With full and unqualified authority to delegate any or all of the foregoing powers to any person or persons whom my attorney(s)-in-fact shall select; 


Third: Hereby ratifying and confirming all that said attorney(s) or substitute(s) do or cause to be done. 


In Witness Whereof I have hereunto signed my name and affixed my seal this ______ day of ______________, 20_____. 

________________________ (Signature of Principal) (Seal)

On the date written above, ________________________________________________

declared to us that this instrument was [his/her] durable power of attorney, and request us to act as witnesses to it. [He/She] signed it in our presence, all of us being present at the same time. We now sign this instrument as witnesses.

________________________, Witness ________________________

________________________, Witness ________________________

ACKNOWLEDGMENT

STATE OF ____________________

COUNTY OF _______________ 

The foregoing instrument was acknowledged before me this ______ ____________________ by  ____________________.

_________________________ (Signature)

Title or Rank  _________________________ 

Serial No. if any  _________________________