A document substantially in the following form may be used to create a statutory form power of attorney that has the meaning and effect prescribed by NRS 162A.200 to 162A.660, inclusive:
STATUTORY FORM POWER OF ATTORNEY
THIS IS AN IMPORTANT LEGAL DOCUMENT. IT CREATES A DURABLE POWER OF ATTORNEY FOR FINANCIAL MATTERS. BEFORE EXECUTING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:
I, ................................................................................................................................
(insert your name) do hereby designate and appoint:
Name: ................................................................................................................
Address: ............................................................................................................
Telephone Number: .........................................................................................
as my agent to make decisions for me and in my name, place and stead and for my use and benefit and to exercise the powers as authorized in this document.
(You are not required to designate any alternative agent but you may do so. Any alternative agent you designate will be able to make the same decisions as the agent designated above in the event that he or she is unable or unwilling to act as your agent. Also, if the agent designated in paragraph 1 is your spouse, his or her designation as your agent is automatically revoked by law if your marriage is dissolved.)
If my agent is unable or unwilling to act for me, then I designate the following person(s) to serve as my agent as authorized in this document, such person(s) to serve in the order listed below:
Name:.....................................................................................................
Address:.................................................................................................
Telephone Number:.............................................................................
Name:.....................................................................................................
Address:.................................................................................................
Telephone Number:.............................................................................
This Power of Attorney is intended to, and does, revoke any prior Power of Attorney for financial matters I have previously executed.
If, after execution of this Power of Attorney, proceedings seeking an adjudication of incapacity are initiated either for my estate or my person, I hereby nominate as my guardian or conservator for consideration by the court my agent herein named, in the order named.
I grant my agent and any successor agent(s) general authority to act for me with respect to the following subjects:
(INITIAL each subject you want to include in the agent's general authority. If you wish to grant general authority over all of the subjects you may initial "All Preceding Subjects" instead of initialing each subject.)
[.....] Real Property
[.....] Tangible Personal Property
[.....] Stocks and Bonds
[.....] Commodities and Options
[.....] Banks and Other Financial Institutions
[.....] Safe Deposit Boxes
[.....] Operation of Entity or Business
[.....] Insurance and Annuities
[.....] Estates, Trusts and Other Beneficial Interests
[.....] Legal Affairs, Claims and Litigation
[.....] Personal Maintenance
[.....] Benefits from Governmental Programs or Civil or Military Service
[.....] Retirement Plans
[.....] Taxes
[.....] All Preceding Subjects
My agent MAY NOT do any of the following specific acts for me UNLESS I have INITIALED the specific authority listed below:
(CAUTION: Granting any of the following will give your agent the authority to take actions that could significantly reduce your property or change how your property is distributed at your death. INITIAL ONLY the specific authority you WANT to give your agent.)
[.....] Create, amend, revoke or terminate an inter vivos, family, living, irrevocable or revocable trust
[.....] Make a gift, subject to the limitations of NRS and any special instructions in this Power of Attorney
[.....] Create or change rights of survivorship
[.....] Create or change a beneficiary designation
[.....] Waive the principal's right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan
[.....] Exercise fiduciary powers that the principal has authority to delegate
[.....] Disclaim or refuse an interest in property, including a power of appointment
[.....] It is my intention to live in my home as long as it is safe and my medical needs can be met. My agent may arrange for a natural person, employee of an agency or provider of community-based services to come into my home to provide care for me. When it is no longer safe for me to live in my home, I authorize my agent to place me in a facility or home that can provide any medical assistance and support in my activities of daily living that I require. Before being placed in such a facility or home, I wish for my agent to discuss and share information concerning the placement with me.
[.....] It is my intention to live in my home for as long as possible without regard for my medical needs, personal safety or ability to engage in activities of daily living. My agent may arrange for a natural person, an employee of an agency or a provider of community-based services to come into my home and provide care for me. I understand that, before I may be placed in a facility or home other than the home in which I currently reside, a guardian must be appointed for me.
[.....] I desire for my agent to take the following actions relating to my care:
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
An agent that is not my spouse MAY NOT use my property to benefit the agent or a person to whom the agent owes an obligation of support unless I have included that authority in the Special Instructions.
Except as otherwise expressly provided in this Power of Attorney, the authority of a principal to act on his or her own behalf continues after executing this Power of Attorney and any decision or instruction communicated by the principal supersedes any inconsistent decision or instruction communicated by an agent appointed pursuant to this Power of Attorney.
[.....] DURABLE. This Power of Attorney shall not be affected by my subsequent disability or incapacity.
[.....] SPRINGING POWER. It is my intention and direction that my designated agent, and any person or entity that my designated agent may transact business with on my behalf, may rely on a written medical opinion issued by a licensed medical doctor stating that I am disabled or incapacitated, and incapable of managing my affairs, and that said medical opinion shall establish whether or not I am under a disability for the purpose of establishing the authority of my designated agent to act in accordance with this Power of Attorney.
[.....] I wish to have this Power of Attorney become effective on the following date: .....
[.....] I wish to have this Power of Attorney end on the following date: .....
Third parties may rely upon the validity of this Power of Attorney or a copy and the representations of my agent as to all matters relating to any power granted to my agent, and no person or agency who relies upon the representation of my agent, or the authority granted by my agent, shall incur any liability to me or my estate as a result of permitting my agent to exercise any power unless a third party knows or has reason to know this Power of Attorney has terminated or is invalid.
I agree to, authorize and allow full release of information, by any government agency, business, creditor or third party who may have information pertaining to my assets or income, to my agent named herein.
I sign my name to this Power of Attorney on .............. (date) at .............................. (city), ......................... (state)
.......................................................
(Signature)
CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC
(You may use acknowledgment before a notary public instead of the statement of witnesses.)
State of Nevada }
}ss.
County of................................................ }
On this .......... day of .........., in the year ....., before me, ............................... (here insert name of notary public) personally appeared .............................. (here insert name of principal) personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to this instrument, and acknowledged that he or she executed it.
NOTARY SEAL ...............................................................
(Signature of Notary Public)
IMPORTANT INFORMATION FOR AGENT
(Principal's Name) by (Your Signature) as Agent
If you violate NRS 162A.200 to 162A.660, inclusive, or act outside the authority granted in this Power of Attorney, you may be liable for any damages caused by your violation.
NRS 162A.620