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Nebraska Power of Attorney <br />DESIGNATION OF AGENT <br />ph-4 r- S o n <br />1 bG 1^ + G 1n 4. (your name) name the following person as my <br />agent (individual with power of attorney): <br />Agent: t\ 6 I H e t' . RI 4- e le S O b <br />Address: , RoSebrt ' a r 0.4, L, r Go 1 In <br />&E <br />Telephone Number: 46 a 4l 3- 755 <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: f74 c h L , P4 44 C. r c o An J r, <br />Address: o'L t'1�' . bm11z Ui ( ra hct 1 elh � N <br />Telephone Number: 4/j 4 2, I/ 3 s':=2_ G PLO, <br />If my successor agent is unable or unwilling to act for me, I name as my second <br />successor 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, <br />to 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 <br />to the following subjects (as defined in the Nebraska Uniform Power of Attorney Act): <br />(CHECK ❑ Yes or ❑ 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. 03/16 § 304041 <br />201805084 <br />Page 1 of 4 <br />