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202305626 <br />Surrogate Decision Making in Nebraska Nebraska State Unit on Aging <br />Nebraska Power of Attorney <br />DESIGNATION OF AGENT <br />I, once Ile sk-erinQv (your name) name the following person as my agent <br />(individual with power of attorney): <br />Agent- S. E,Wnirev-, <br />Address: b ati Lusk 154-'x' S\-. -��o ,��s�a�-,e1 J1rf, t'l- <br />Phone Number: 3(DS - `(5) —11)-1 <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: 7c44%,ts. r:c 1Lrr ,r-1 <br />Address: Lo . LI z s 1!� ` SlereeA 0-- v-c.Lry TS1 ax, -1 , {a. LAO <br />Phone Number- 3(:).- <br />If <br />i' <br />If my agent is unable or unwilling to act for me, I name as my second successor agent (OPTIONAL): <br />Name of Second Successor Agent: <br />Address: <br />Phone Number - <br />RELEASE OF INFORMATION <br />I agree to, authorize, and allow full release of information, by any governmental agency, business, <br />creditor, or third party who may have information pertaining to my assets or income, to my agent named <br />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 the following <br />subjects (as defined in the Nebraska Uniform Power of Attorney Act): <br />(CHECK or El No AND initial for each of the subjects that follow. These subjects represent those you <br />may want to include in the agent's general authority. If you wish to grant general authority over all of the <br />subjects you may check Efirg for "All Preceding Subjects" AND initial that line instead of checking each <br />subject.) <br />Check one: Initials: <br />❑Yes ❑No Real Property <br />❑Yes ❑No Tangible Personal Property <br />❑Yes ❑No Stocks and Bonds <br />MLTC-PB-3 (99009) 2/21 <br />