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NOMINATION OF [CONSERVATOR OR GUARDIAN] (OPTIONAL) <br />If it becomes necessary for a court to appoint a conservator of my estate or guardian of my <br />person, I nominate the following person(s) for appointment: <br />Name of Nominee for conservator of my estate <br />Nominee's Address: <br />Nominee's Telephone Number: <br />Name of Nominee for guardian of my person: <br />Nominee's Address: <br />Nominee's Telephone Number: <br />RELIANCE ON THIS POWER OF ATTORNEY <br />Any person, including my agent, may rely upon the validity of this power of attorney or a copy of it <br />unless that person knows it has terminated or is invalid. <br />Date: <br />State of Nebraska ) <br />)ss <br />County of .Hi/ LL <br />This docme was acknowledged before me on <br />(Name of Principal) <br />(S <br />GENERAL NOTARY- Slat Bi kebiaska <br />LAYLA M CROW <br />My Comm. Exp. May 14, 2017 <br />SIGNATURE AND ACKNO LEDGE EN <br />Your signature `�-'�?�•ti�t �' c�-S� <br />Your address 1%&3...C19.40,/.0. <br />j ...C19L0L!►0, ... � <br />gmegD.... NE <br />Your Telephone Nbr: .3 0 <br />/IT ...... <br />N • f 1 " ublic <br />My Commission expires: <br />201801817 <br />