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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 />State of Nebraska <br />County of AttA <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 />SIGNATURE AND ACKN9WLEDGEMENT <br />Your signature <br />Your address z-7 6 3 C- } /:z7 ..... Doc - <br />Your Telephone Nbr: Q. .- �.�..y. 7.34 g.3 <br />Date: %. /�'.. <br />)ss <br />This document a ias acknowledged before me on 1 <br />Ln b. <br />(Name of Principal) <br />(Seal, if any) <br />GENERAL NO1ARY - State at Nebraska <br />TORRIE WISEMAN <br />My Comm. Exp. May 26, 2019 <br />201801818 <br />ti <br />r1 iteivetsuim <br />Notary Public <br />My Commission expires: .5.12r4e. 12011 <br />