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201800818 <br />Nebraska Power of Attorney <br />DESIGNATION OF AGENT <br />I (I t ,i /i L c L/i [ L' 1-. (your name) name the following person as my <br />agent (individual with power of attorney): gay Agent: _: J �1 v1/ 1--• } A" <br />Address: 6 ;* !/rlvY ' ✓GMT" ,� /t✓' l� <br />Telephone Number: 30tf = S F'I ^h' 2 ,4 <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: <br />Address: <br />Telephone Number: <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 Attotney Act): <br />(CHECK ❑ Yes or n 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 />