HomeMy WebLinkAbout10-19 Power of AttorneyVIRGINIA
LIMITED POWER OF ATTORNEY FORM
I. NOTICE - This legal document grants you (Hereinafter referred to as the
"Principal") the right to transfer limited financial powers to someone else
(Hereinafter referred to as the "Attorney -in -Fact"), limited financial powers
are described as: any specific financial act legal under law. The Principal's
transfer of limited financial powers to the Attorney -in -Fact are granted upon
authorization of this agreement, and ONLY remains in effect until the
completion of said act, unless the Principal becomes incapacitated
(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 Limited 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 Limited Power of Attorney Form, it will revoke any
previously valid Limited Power of Attorney Form.
II. INCAPACITATION - The powers granted to the Attorney -in -Fact by the
Principal in this Limited Power of Attorney Form DO NOT 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 Limited Power of
Attorney Form at anytime. Any revocation will be effective if the Principal:
A. Authorizes a new Limited Power of Attorney Form.
B. Authorizes a Power of Attorney Revocation Form.
IV. WITNESS Ft NOTARY - This document is not valid as a Limited 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
Limited Power of Attorney Form notarized.
Trustee New Life Christian Church
V. PRINCIPAL - I, , residing at
Name of Principal
2930 Middle Road
Street Address of Principal
City of Winchester , State of Virginia , appoint
City of Principal State of Principal
the following as my Attorney -in -Fact, whom I trust with a specific financial act
or acts immediately upon the authorization of this form, and I grant the power
to act as if I were personally present to
VI. ATTORNEY-IN-FACT - Paul L. Carper , residing at
Name of Attorney -in -Fact
97 Molden Dr.
Street Address of Attorney -in -Fact
City of Winchester , State of Virginia grant
City of Attorney -in -Fact State of Attorney -in -Fact
the Attorney -in -Fact the legal authority for a specific financial act on my
behalf that can be any power legal under law in the State of
Virginia . The Specific financial act I grant my Attorney -in -
State
Fact is:
sign and submit application and documents as applies to the overflow gravel area for New Life Christian Church
A Detailed Description of Exact Powers granted
VII. SUCCESSOR ATTORNEY-IN-FACT (Optional) - If the Attorney -in -Fact named
abo�annot or is unwilling to serve, then I appoint ,
Name of Succney-in-Fact
residing at:
of Successor A ttoroef--in -Fact
City of grant
City of Successor Attorney -in -Fact State of Successor Attorney -in -Fact
the Attorney -in -Fact the legs hority for ecific financial act on my
behalf that can be any pqw6r legal under law in _State of
The Specific financial act I >; t my Successor
Attorrjel--in-Fact is:
and submit application and documents as applies to the overflow gravel area for New Life Christian
A Detailed Description of Exact Powers granted
Trustee New Life Christian Church
V. PRINCIPAL - I, , residing at
Name of Principal
2930 Middle Road
Street Address of Principal
City of Winchester , State of Virginia , appoint
City of Principal State of Principal
the following as my Attorney -in -Fact, whom I trust with a specific financial act
or acts immediately upon the authorization of this form, and I grant the power
to act as if I were personally present to
VI. ATTORNEY-IN-FACT - Paul L. Carper , residing at
Name of Attorney -in -Fact
97 Molden Dr.
city of Winchester
Street Address of Attorney -in -Fact
State of Virginia
grant
City of Attorney -in -Fact State of Attorney -in -Fact
the Attorney -in -Fact the legal authority for a specific financial act on my
behalf that can be any power legal under law in the State of
Virginia . The Specific financial act I grant my Attorney -in -
State
Fact is:
sign and submit application and documents as applies to the overflow gravel parking area for New Life Christian Church
A Detailed Description of Exact Powers granted
. SUCCESSOR ATTORNEY-IN-FACT (Optional) - If the Attorney -in -Fact na
above c of or is unwilling to serve, then I appoint
Name of
residing at:
City of
City of Successor Attorney -in -Fact
the Attorney -in -Fact the legal
behalf that can be any po leg
act is:
of Successor
A grant
t�ofSuccessor Attorney -in -Fact
ority for c financial act on my
under laState of
. The Specific financial act I 'grang my Successor
submit application and documents as applies to the overflow gravel parking area for New Life
A Detailed Description of Exact Powers granted
VIII. TERMS £t 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
Limited 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� Trustees New Life Christian Church , the
Printed Name of Principal
Principal, sign my name to this power of attorney this 24th day of
March Day
and, being first duly sworn, do declare to the
Month
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
aadu_�der no wristrainx Syr undue influence.
Of
Clry/County of T-- keA v r i , K
Cm nonweam of Virginia
Sub+ori and sworn to ore me
day of rnr .20 �CA
by,.� 'r G S ,,-�
liftry Pubk's 800ft
:gyp•.• • • • '•�.'%;
0 4,9
Notary Acknowledgement (Must be completed by Notary)
State of, i : o- County of T--v-� A e r i LK Subscribed,
Sworn and acknowledged before me by D eu -)L�u S ; �I< A -i ��\v. Vi4eC , the
Principal, and subscribed and sworn to before me by � ,
witness, this day of "A aA CA
\\\\pH111111//►►ph'
Notary Signature .0,�P''
0: Ak0.0
rAAY..c�
o: evc
Notary Public o ; �v"M 1 _
In and for the County of
State of kil c
My commission expires: s 3\ L� 3 Seal
Acknowledgement and Acceptance of Appointment as Attorney -in -Fact
I -t'
I, , L_ L - OiW pFV have read the attached power of attorney
Name of Attorney -in -Fact
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
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.
ignature of Attorney -in -Fa 9t Date
Acceptance of Appointment as successor Attorney -in -Fact
M
have read the attached ooh of
Name of succ Attorney -in -Fact
attorney and am the son identified a<specific
sso orney-in-fact for the
principal. I hereby acknow a that I apointment as Successor
Attorney -in -Fact and that, in the enccific provision to the contrary
in the power of attorney, when I actll exercise the powers for
the benefit of the principal; I sh eep of the principal separate
from my assets; I shall exe a reasonarudence; and I shall
keep a full and accur record of all acipts, a isbursements on
behalf of the p ' pat.
of Successor Attorney -in -Fact
Date