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Nebraska Power of Attorney <br />201707392 <br />DESIGNATION OF AGENT <br />I ctCjc e 61, @,isT (your name) name the following person as my <br />agent (individual with power of attorney): <br />Agent: %C.1\4 Pd L, j l° -i CJ r <br />Address: <br />y ,QQj Ihdi <br />Telephone Number: ' 9 0- $'4 ZO <br />DESIGNATION OF SUCCESSOR AGENT(S) (OPTIONAL) <br />If my agent is unable or unwilling to act for me, I name as my successor agent: <br />Name of Successor Agent: e R . &St,U 1. GE.iST <br />Address: ya3y (4 -iWbd4 p� <br />Telephone Number: 3 0 P- 370 - 9 0 3 <br />If my successor agent is unable or unwilling to act for me, I name as my second successor <br />agent (OPTIONAL): <br />Name of Second Successor Agent: <br />Address: <br />Telephone Number: <br />RELEASE OF INFORMATION <br />I agree to, authorize, and allow full release of information, by any governmental agency, <br />business, creditor, or third party who may have information pertaining to my assets or income, to <br />my agent named on this form. <br />GRANT OF GENERAL AUTHORITY <br />I grant my agent and any successor agent general authority to act for me with respect to <br />the following subjects (as defined in the Nebraska Uniform Power of Attorney Act): <br />(CHECK ❑ Yes or (1 No AND initial for each of the subjects that follow. These <br />subjects represent those you may want to include in the agent's general authority. If you wish to <br />grant general authority over all of the subjects you may check ❑ Yes for "All Preceding <br />Subjects" AND initial that line instead of checking each subject.) <br />Power of Attorney, DC 6:12 PSC, Rev. 08/12 §30 -4041 <br />Page 1 of 4 <br />