NEW HAMPSHIRE DURABLE POWER OF ATTRONEY FORM
I. NOTICE – This legal document grants you (Hereinafter referred to as the “Principal”) the right to transfer unlimited financial powers to someone else (Hereinafter referred to as the “Attorney-in-Fact”), unlimited financial powers are described as: all financial decision making power legal under law. The Principal’s transfer of financial powers to the Attorney-in-Fact are granted upon authorization of this agreement, and stay in effect in the event of incapacitation by the Principal (incapacitation is described in Paragraph II). This agreement does not authorize the Attorney-in-Fact to make medical decisions for the Principal. The Principal continues to retain every right to all their financial decision making power and may revoke this Durable Power of Attorney Form at anytime. The Principal may include restrictions or requests pertaining to the financial decision making power of the Attorney-in-Fact. It is the intent of the Attorney-in-Fact to act in the Principal’s wishes put forth, or, to make financial decisions that fit the Principal’s best interest. All parties authorizing this agreement must be at least 18 years of age and acting under
no false pressures or outside influences. Upon authorization of this Durable Power of Attorney Form, it will revoke any previously valid Durable Power of Attorney Form.
II. INCAPACITATION – The powers granted to the Attorney-in-Fact by the Principal in this Durable Power of Attorney Form stay in effect upon incapacitation by the Principal, incapacitation is describes as: A medical physician stating verbally or in writing that the Principal can no longer make decisions for them self.
III. REVOCATION – The Principal has the right to revoke this Durable Power of Attorney Form at anytime. Any revocation will be effective if the Principal either:
A. Authorizes a new Durable Power of Attorney Form.
B. Authorizes a Power of Attorney Revocation Form.
IV. WITNESS & NOTARY – This document is not valid as a Durable Power of Attorney unless it is acknowledged before a notary public or is signed by at least two adult witnesses who are present when the Principal signs or acknowledges the Principal’s signature. It is recommended to have this Durable Power of Attorney Form notarized.

V. PRINCIPAL
I, (Name of Principal)
residing at (Street Address of Principal)
residing at (Street Address of Principal)
City of
(City of Principal)
State of
(State of Principal)
appoint the following as my Attorney-in-Fact, whom I trust with any and all my financial decision making power immediately upon the authorization of this form, and in the event that I should become incapacitated:
VI. ATTORNEY-IN-FACT
(Name of Attorney-in-Fact)
(Name of Attorney-in-Fact)
residing at (Street Address of Attorney-in-Fact)
residing at (Street Address of Attorney-in-Fact)
City of
City of Attorney-in-Fact
State of
State of Attorney-in-Fact
grant the Attorney-in-Fact the legal authority to act on my behalf for any power legal under law in regard to my financial decisions under the State of
State
VII. SUCCESSOR ATTORNEY-IN-FACT (Optional)
If the Attorney-in-Fact named above cannot or is unwilling to serve, then I appoint
Name of Successor Attorney-in-Fact
residing at (Street Address of Successor Attorney-in-Fact)
residing at (Street Address of Successor Attorney-in-Fact)
City of
City of Successor Attorney-in-Fact
State of
State of Successor Attorney-in-Fact
grant the Attorney-in-Fact the legal authority to act on my behalf for any power legal under law in regard to my financial decisions under the State of
State
State
VIII. TERMS & CONDITIONS – Upon authorization by all parties, the Attorney-in- Fact accepts their designation to act in the Principal’s best interests for all financial decisions legal under law.

IX. THIRD PARTIES – I, the Principal, agree that any third party receiving a copy via: physical copy, email, or fax that I, the Principal, will indemnify and hold harmless any and all claims that may be put forth in reference to this Durable Power of Attorney Form.
X. COMPENSATION – The Attorney-in-Fact agrees not to be compensated for acting in the presence of the Principal. The Attorney-in-Fact may be, but not entitled to, reimbursement for all: food, travel, and lodging expenses for acting in the presence of the Principal.
XI. DISCLOSURE – I intend for my attorney-in-fact under this Power of Attorney to be treated, as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (aka HIPAA), 42 USC 1320d and 45 CFR 160-164
XII. PRINCIPAL’S SIGNATURE
I,
the Principal, (Printed Name of Principal)
sign my name to this power of attorney this (date)
MM slash DD slash YYYY

sign my name to this power of attorney this (date)
and, being first duly sworn, do declare to the undersigned authority that I sign and execute this instrument as my power of attorney and that I sign it willingly, or willingly direct another to sign for me, that I execute it as my free and voluntary act for the purposes expressed in the power of attorney and that I am eighteen years of age or older, of sound mind and under no constraint or undue influence.
Signature of Principal
XIII. ATTORNEY-IN-FACT’S SIGNATURE
I,
Name of Attorney-in-Fact
have read the attached power of attorney and am the person identified as the attorney-in-fact for the principal. I hereby acknowledge and accept my appointment as Attorney-in-Fact and that when I act as agent I shall exercise the powers for the benefit of the principal; I shall keep the assets of the principal separate from my assets; I shall exercise reasonable caution and prudence; and I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal.
Signature of Attorney-in-Fact
Date
MM slash DD slash YYYY

XIV. SUCCESSOR ATTORNEY-IN-FACT’S SIGNATURE (Optional)
I,
Name of successor Attorney-in-Fact
have read the attached power of attorney and am the person identified as the successor attorney-in-fact for the principal. I hereby acknowledge that I accept my appointment as Successor Attorney-in-Fact and that, in the absence of a specific provision to the contrary in the power of attorney, when I act as agent I shall exercise the powers for the benefit of the principal; I shall keep the assets of the principal separate from my assets; I shall exercise reasonable caution and prudence; and I shall keep a full and accurate record of all actions, receipts, and disbursements on behalf of the principal.
Signature of Successor Attorney-in-Fact
Date
MM slash DD slash YYYY

Notary Acknowledgement (Must be completed by Notary)
State of
County of
Subscribed, Sworn and acknowledged before me by
the Principal, and subscribed and sworn to before me by
witness, this
MM slash DD slash YYYY
Notary Signature
Notary Public
In and for the County of
State of
My commission expires:
MM slash DD slash YYYY
Acknowledgement and Acceptance of Appointment as Attorney-in-Fact
I,
(Name of Attorney-in-Fact) have read the attached power of attorney and am the person identified as the attorney-in-fact for the principal. I hereby acknowledge that accept my appointment as Attorney-in-Fact and that when I act as agent I shall exercise the powers for the benefit of the principal; I shall keep the assets of the principal separate from my assets; I shall exercise reasonable caution and prudence; and I shall keep a full and accurate of all actions, receipts and disbursements on behalf of the principal.
Signature of Attorney-in-Fact
Date
MM slash DD slash YYYY
Acceptance of Appointment as successor Attorney-in-Fact
I,
(Name of successor Attorney-in-Fact)
have read the attached power of attorney and am the person identified as the successor attorney-in-fact for the principal. I hereby acknowledge that I accept my appointment as Successor Attorney-in-Fact and that, in the absence of a specific provision to the contrary in the power of attorney, when I act as agent I shall exercise the powers for the benefit of the principal; I shall keep the assets of the principal separate from my assets; I shall exercise reasonable caution and prudence; and I shall keep a full and accurate record of all actions, receipts, and disbursements on behalf of the principal.
Signature of Successor Attorney-in-Fact
Date
MM slash DD slash YYYY

Witness Attestation
I, (Printed Name of First Witness)
I, (Printed Name of First Witness)
the first witness, and I (Printed Name of Second Witness)
the first witness, and I (Printed Name of Second Witness)
the second witness, sign my name to the foregoing power of attorney being first duly sworn and do not declare to the undersigned authority that the principal signs and executed this instrument as him or her, and that I, in the presence and hearing of the principal, sign this power of attorney as witness to the principal’s signing and that to the best of my knowledge the principal is eighteen years of age or older, of sound mind and under no constraint or undue influence.
Signature of First Witness
Signature of Second Witness
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[Health Care Directive] New Hampshire

[Power Of Attorney] New Hampshire

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NEW HAMPSHIRE DURABLE POWER OF ATTRONEY FORM

Witness Attestation