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...:;:t,........„it202401 880 <br />•I Nebraska State Unit on A <br />Surro•ate Decision Makihin Nebraska <br />Nebeaska Power of Attorney <br />r <br />DESIGNATION OF AGENT <br />444 <br />1 (individual with p oWer of attorney): <br />Agent: 1 <br />,µ, <br />Address: 50 3 E. <br />la*`‘ <br />34 <br />phone Number: <br />,dog -1514 .7 <br />(your name) name the following person as my agent <br />rang aikka A)& (o pI <br />DESIGNATION OF SUCCESSOR AGENT(S) (OPTIONAL) agent <br />If my agent is unable or unwilling to act for me, 1 name as my successor 9 <br />t/ c KE . <br />Agent <br />Name of Successor Ag c:1 n <br />�1 -oe Vra.nt.• ta.•��f A <br />80 3 <br />J0.•._ .000c <br />Address: i <br />Phone Number 662 <br />agent is unable or unwilling to act for me, 1 name as my second successor agent (OPTIONAL): <br />If my <br />Name of Second Successor Agent An 4 C .e. L g&'� <br />Address: <br />'' S5b Qm- d.-1- -go at r a- <br />Phone Number: 3 <br />RELEASE OF INFORMATION agency, business, <br />1 agree to, authorize, and allow full release of information, by any governmentalor income, cco my agent named <br />creditor, or third party who may have information pertaining to my assets <br />on this form. <br />GRANT OF GENERAL AUTHORITY <br />1rant my agent and any successor agent general authority to act for me with respect to the following <br />g <br />subjects (as defined in the Nebraska Uniform Power pf Attorney Aot . <br />(CHECK Q Y <br />�� <br />or !�— <br />g aru lnitlal for each of the subjects that follow.may r • , <br />want to include in the agent's general authority. Ifyou �wish to grant generaAlillinitIalluallue.l authorityt overaler l o each <br />subjects you may check OAS. for "All Preceding Subjects <br />subject.) <br />Check one: Initials: <br />DYes ❑No - Real Property <br />DYes 0No Tangible Personal Property <br />OYes DNo Stocks and Bonds <br />MLTC•P83 (99009) 2/21 <br />