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20240291 <br />✓� Printing the form and ndwritiing <br />h <br />the answers. <br />0 Completing the form electronically. <br />Nebraska Power of Attorney <br />DESIGNATION OF AGENT <br />5/4 iM VEL is your name) name the fol lowing person as my agent <br />(individual with power of attorney): <br />Agent: Lyd1 a.. Pas a !/ +alai <br />Address: 1 %3 Z (N la" S T 2Ee T C, u D /SC.4AJWfes' <br />Telephone Number. (30 $) fir,,- j 4/0 <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: AOI I 1 d f 3 $t / es+' 1 111. <br />Address: 1 f 3 z tnt t Z,rh n i4 IV ip 131d4-6) 0 Afi Utft.0 <br />Telephone Number. L fL7' 7$ 7 -ct 72,9 <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 to the <br />following subjects (as defined in the Nebraska Uniform Power of Attorney Act): <br />(CHECK ❑ Yes or 0 No AND initial for each of the subjects that follow. These subiects <br />represent those You may want to Include In the agent's general authority. If you wish to grant <br />general authority over all of the subjects you may check ❑ las for "All Preceding Subjects" <br />AND initial that line instead of checking each subject.) <br />Power of Attorney, DC 6:12 PSC, Rev. 11/2023 § 30-4041 Page 1 of 4 <br />