I, ________(1)__________, of ________(2)____________, hereby appoint
__________(3)____________, of _________(4)_____________, as my attorney to act in my capacity to do every act that I may legally do through an attorney.   This power shall be in full force and effect on the date below written and shall remain in full force and effect until _______(5)____________ or unless specifically extended or rescinded earlier by either party.

 

Dated _______(6)____________, 19_(7)__.

____________(8)_______________

 

STATE OF _________(9)___________

COUNTY OF ________(10)__________

 

BEFORE ME, the undersigned authority, on this _(11)_ day of _______(12)_______, 19_(13)_, personally appeared _______(14)_______________ to me well known to be the person described in and who signed the Foregoing, and acknowledged to me that he executed the same freely and voluntarily for the uses and purposes therein expressed.

 

WITNESS my hand and official seal the date aforesaid.

_____________(15)____________

 

NOTARY PUBLIC

 

My Commission Expires:__(16)__

 

 

 

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