W. Va. Code § 39B-3-101
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 this act.
State of West Virginia
STATUTORY FORMPOWER OF ATTORNEY
IMPORTANT INFORMATION
This power of attorney authorizes another person (your agent) to make decisions concerning your property for you (the principal). Your agent will be able to make decisions and act with respect to your property (including your money) whether or not you are able to act for yourself. The meaning of authority over subjects listed on this form is explained in the Uniform Power of Attorney Act, §39B-1-101 et seq. of this code.
This power of attorney does not authorize the agent to make health care decisions for you.
You should select someone you trust to serve as your agent. Unless you specify otherwise, generally the agent's authority will continue until you die or revoke the power of attorney or the agent resigns or is unable to act for you.
Your agent is entitled to reasonable compensation unless you state otherwise in the special instructions. This form provides for designation of one agent. If you wish to name more than one agent you may name a coagent in the Special Instructions. Coagents are not required to act together unless you include that requirement in the Special Instructions. If your agent is unable or unwilling to act for you, your power of attorney will end unless you have named a successor agent. You may also name a second successor agent.
This power of attorney becomes effective immediately unless you state otherwise in the Special Instructions.
If you have questions about the power of attorney or the authority you are granting to your agent, you should seek legal advice before signing this form.
DESIGNATION OF AGENT
I __________________________ name the following person as my agent:
(Name of Principal)
Name of Agent: ____________________________________________________
Agent's Address: ___________________________________________________
Agent's Telephone Number: __________________________________________
If my agent is unable or unwilling to act for me, I name as my successor agent:
Name of Successor Agent: __________________________________________
Successor Agent's Address: _________________________________________
Successor Agent's Telephone Number: ________________________________
If my successor agent is unable or unwilling to act for me, I name as my second successor agent:
Name of Second Successor Agent: ____________________________________
Second Successor Agent's Address: ___________________________________
Second Successor Agent's Telephone Number: __________________________
GRANT OF GENERAL AUTHORITY
I grant my agent and any successor agent general authority to act for me with respect to the following subjects as defined in the Uniform Power of Attorney Act, §39B-1-101 et seq. of this code:
(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
(___) Operation of Entity or Business
(___) Insurance and Annuities
(___) Estates, Trusts, and Other Beneficial Interests
(___) Claims and Litigation
(___) Personal and Family Maintenance
(___) Benefits from Governmental Programs or Civil or Military Service
(___) Retirement Plans
(___) Taxes
(___) All Preceding Subjects
GRANT OF SPECIFIC AUTHORITY (OPTIONAL)
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 trust
(___) Make a gift, subject to the limitations of the West Virginia Uniform Power of Attorney Act and any special instructions in this power of attorney
(___) Create or change rights of survivorship
(___) Create or change a beneficiary designation
(___) Authorize another person to exercise the authority granted under this power of attorney
(___) 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
(___) Access the content of electronic communications
LIMITATION ON AGENT'S AUTHORITY
An agent that is not my ancestor, spouse, or descendant 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.
SPECIAL INSTRUCTIONS (OPTIONAL)
You may give special instructions on the following lines:
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
EFFECTIVE DATE
This power of attorney is effective immediately unless I have stated otherwise in the special instructions.
NOMINATION OF [CONSERVATOR OR GUARDIAN] (OPTIONAL)
If it becomes necessary for a court to appoint a [conservator or guardian] of my estate or [guardian] of my person, I nominate the following person(s) for appointment:
Name of Nominee for [conservator or guardian] of my estate:
_________________________________________________________________
Nominee's Address: _________________________________________________
Nominee's Telephone Number: ________________________________________
Name of Nominee for [guardian] of my person: ____________________________
Nominee's Address: _________________________________________________
Nominee's Telephone Number: ________________________________________
RELIANCE ON THIS POWER OF ATTORNEY
Any person, including my agent, may rely upon the validity of this power of attorney or a copy of it unless that person knows it has terminated or is invalid. Unless expressly stated otherwise, this power of attorney is durable and shall remain valid if I become incapacitated.
SIGNATURE AND ACKNOWLEDGMENT
_________________________________________________________________
Your Signature _______________________________ Date __________________
Your Name Printed __________________________________________________
Your Address ______________________________________________________
Your Telephone Number _____________________________________________
State of ___________________________________
[County] of _________________________________
This document was acknowledged before me on ________________ ,
(Date)
by ______________________________________.
(Name of Principal)
_______________________________________________ (Seal, if any)
Signature of Notary
My commission expires: ________________________
[This document prepared by: _______________________________________ ]
IMPORTANT INFORMATION FOR AGENT
Agent's Duties
When you accept the authority granted under this power of attorney, a special legal relationship is created between you and the principal. This relationship imposes upon you legal duties that continue until you resign or the power of attorney is terminated or revoked. You must:
____________________________ by ______________________________
(Principal's Name) (Your Signature) as Agent
Unless the special instructions in this power of attorney state otherwise, you must also:
Termination of Agent's Authority
You must stop acting on behalf of the principal if you learn of any event that terminates this power of attorney or your authority under this power of attorney. Events that terminate a power of attorney or your authority to act under a power of attorney include:
Liability of Agent
The meaning of the authority granted to you is defined in the Uniform Power of Attorney Act, §39B-1-101 et seq. of this code. If you violate the Uniform Power of Attorney Act, as set forth in §39B-1-101 et seq. of this code, or act outside the authority granted, you may be liable for any damages caused by your violation.
If there is anything about this document or your duties that you do not understand, you should seek legal advice.
W. Va. Code § 39B-3-101