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202305626 Surrogate Decision Making in Nebraska Nebraska State Unit on Aging ❑Yes ❑ No Commodities and Options ❑Yes ❑ No Banks and Other Financial Institutions ❑Yes ❑No Operation of Entity or Business ❑Yes ❑No Insurance and Annuities ❑Yes ❑No Estates, Trusts, and Other Beneficial Interests Claims and Litigation ❑Yes ❑ No Personal and Family Maintenance ElYes ❑ No Benefits from Governmental Programs or Civil or Military Service ❑Yes ❑No Retirement Plans ❑Yes ❑ No Taxes IE'Yes ❑ No 4ad All Preceding Subjects (includes all items listed above) GRANT OF SPECIFIC AUTHORITY (OPTIONAL) My agent MAY do any of the following specific acts for me IF I have CHECKED the specific authority listed below: (CAUTION: Granting any of the following will give your agent the authority to take actions that could significantly reduce your property or change how your property is distributed at your death. CHECK YES AND INITIAL ONLY the specific authority you WANT to give your agent. NOTE: If you do not mark yes and initial the authority, the authority is not granted.) Check one: Initials: Yes ❑ No __ Create, amend, revoke, or terminate an inter vivos trust 124es ❑ No Va Make a gift, subject to the limitations of the Nebraska Uniform Power of Attorney Act and any special instructions in this power of attorney 11Wes ❑ No '10 Create or change rights of survivorship EY%es 0 N V/0 Create or change a beneficiary designation 124es 0 No Vo Delegate to another person to exercise the authority granted under this power of attorney Pies ❑ No `% Waive the principal's right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan E94es ❑ No �� Exercise fiduciary powers that the principal has authority to delegate .M4es ❑No \it, Renounce or disclaim an interest in property, including a power of appointment LIMITATION ON AGENT'S AUTHORITY If I did not check the "Power of Personal and Family Maintenance" or the "All Preceding Subjects" in the Grant of General Authority above, my agent MAY NOT use my property to benefit themselves or anyone they support except for those items listed below in the Special Instructions. MLTC-PB-3 (99009) 2121