La. Stat. tit. 9 § 3862
appoint___________________________________________________
(NAME AND ADDRESS OF THE PERSON APPOINTED, OR OF EACH PERSON APPOINTED IF YOU WANT TO DESIGNATE MORE THAN ONE)
as my agent (attorney-in-fact) to act for me in any lawful way with respect to the following initialed subjects:
TO GRANT OR WITHHOLD ANY OF THE FOLLOWING POWERS, INITIAL THE LINE IN FRONT OF IT IN THE APPROPRIATE COLUMN ("YES" OR "NO"). (THE GRANTING OF POWERS AFFECTING IMMOVABLE PROPERTY IS PROVIDED IN A SEPARATE SECTION.)
YES
NO
____
____
Tangible personal property transactions.
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____
Stock and bond transactions.
____
____
Commodity and option transactions.
____
____
Banking and other financial institution transactions.
____
____
Business operating transactions.
____
____
Insurance and annuity transactions.
____
____
Estate, trust, and other beneficiary transactions.
____
____
Claims and litigation.
____
____
Personal and family maintenance.
____
____
Care, custody, and control of a minor child.
____
____
Benefits from social security, Medicare, Medicaid, or other governmental programs, or civil or military service.
____
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Retirement plan transactions.
____
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Tax matters.
____
____
ALL OF THE POWERS LISTED ABOVE.
YOU NEED NOT INITIAL ANY OTHER LINES IF YOU INITIAL IN THE APPROPRIATE COLUMN ("YES" OR "NO") OF LINE (N).
TO GRANT THE POWER TO AFFECT IMMOVABLE OR REAL PROPERTY WHICH YOU OWN, SUCH AS SELL, LEASE, OR MORTGAGE REAL ESTATE, INITIAL IN THE APPROPRIATE COLUMN ("YES" OR "NO") OF LINE (P) AND PROVIDE LOCATION OF PROPERTY.
YES
NO
____
____
property: _____________________________________
______________________________________________
ON THE FOLLOWING LINES YOU MAY GIVE SPECIAL INSTRUCTIONS LIMITING OR EXTENDING THE POWERS GRANTED TO YOUR AGENT.
________________________________________________________
________________________________________________________
UNLESS YOU DIRECT OTHERWISE ABOVE, THIS POWER OF ATTORNEY IS EFFECTIVE IMMEDIATELY AND WILL CONTINUE UNTIL IT IS REVOKED.
This power of attorney will:
________ Continue to be effective even though I become incapacitated.
________ Terminate when I become incapacitated.
EXERCISE OF POWER OF ATTORNEY WHERE MORE THAN ONE AGENT DESIGNATED
If I have designated more than one agent, the agents are to act:
____ separately or ____ jointly.
I agree that any third party who receives a copy of this document may act under it. I agree that any transaction entered into by any third party in reliance on this document shall be binding upon me and I hereby waive all rights I may have to challenge the authority of the named agent, except to recover against him. Revocation of the power of attorney is not effective as to a third party until the third party has actual knowledge of the revocation.
_____________________________________________________
(Signature)
(SSN - optional)
Done and passed at the Parish of ________________, Louisiana, on the day and date first above written, in the presence of _________________________ and ____________________________, competent witnesses, (two witnesses preferred, but only required if line (P) is initialed) who sign with appearer and me, officer, after due reading of the whole.
WITNESSES:
_______________________________________________________
(address)
_______________________________________________________
(address)
NOTARY SEAL
________________________________________
(SIGNATURE OF NOTARY PUBLIC)
La. R.S. § 9:3862