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202403987 INITIAL ONLY the specific authority you WANT to give your agent.) ( ) Create, amend, revoke, or terminate an intervivos trust ( ) Make a gift, subject to the limitations of the Uniform Power of Authority Act [insert citation to Section 217 of the act] and any specific Instructions in this power of attorney ( ) Create or change rights of survivorship ( ) Create or change a beneficiary designation ( ) Delegate to another person to exercise the authority granted under this power of attorney ( ) Waive the principal's right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan ( ) Exercise fiduciary powers that the principal has authority to delegate ( ) Renounce or disclaim an interest in property, including a power of appointment LIMITATION ON AGENTS AUTHORITY Except as otherwise authorized herein, an agent MAY NOT use my property to benefit the agent or a person to whom the agent owes an obligation of support unless I have included that authority in the Special Instructions or the Grant of Specific Authority. SPECIAL INSTRUCTIONS (OPTIONAL) You may give special instructions on the following lines: I declare that this power of attorney shall become effective upon my disability or incapacity but not until then. A determination that a principal is incapable of making financial decisions shall be made in writing by the attending physician and any physician consulted with respect to the determination that the principal is incapable of making financial decisions, and they shall document the cause and nature of the principal's incapacity. The determination shall be included in the principal's medical record with the attending physician and, when applicable, with the consulting physician and the health care facility in or of which the principal is a patient or resides. In the event that I am living with a family member and not in my home, I direct my attorney-in- fact fairly compensate the family member for their services to me. EFFECTIVE DATE This power of attorney is effective immediately unless I have stated otherwise in the Special Instructions. NOMINATION OF CONSERVATOR AND/OR GUARDIAN If it becomes necessary for a court to appoint a conservator and/or guardian of my estate or a guardian of my person, I nominate the following person for appointment: