BY THIS DOCUMENT IT IS HEREBY ACKNOWLEDGED, that I, [[name of person granting power of attorney] of [city, state], the undersigned, do hereby grant a limited and specific power of attorney to [name of person granted power of attorney] of [city, state] as my attorney-in-fact.

Said attorney-in-fact shall have authority and the power to undertake and perform only the following acts on my behalf: [list specific acts the attorney-in-fact is authorized to perform]. This authority shall also include any incidental acts that are reasonably required to carry out and perform the specific authorities herein granted.

This power of attorney shall be effective upon execution. This power of attorney may be revoked by me at any time. This power of attorney shall automatically be revoked upon my death.

My attorney-in-fact agrees to this appointment subject to its terms. My attorney-in-fact agrees to act as my fiduciary and in my best interests, as seems advisable to the best of his discretion.

Signed under seal this [day, e.g. 1st] day of [month], [year].


STATE OF _____________________

COUNTY OF ____________________

In _______________, on the _____________ day of ____________, 19___, before me, a Notary Public in and for the above state and county, personally appeared [tenant], known to me or proved to be the person named in and who executed the foregoing instrument, and being first duly sworn, such person acknowledged that he or she executed said instrument for the purposes therein contained as his or her free and voluntary act and deed.

_______________________________ NOTARY PUBLIC

My Commission Expires: ________


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