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UMWZi/ZUZ4/MUN 11; 34 AM <br />1U14/11/S0o9:48:It .S /S <br />FAX No, <br />202504377 <br />P. 002 <br />Power Of Attorney (POA) Activation For Amy Polkas <br />Patient Amy E. Polkers <br />Date of Birth: 05-25-1932 <br />Resident of Country House Grand Island NE <br />Condition: Dementia <br />This letter Is to certify that Amy E. Folkers Is mentally Incapacitated & <br />financially Incompetent due to her condition of dementia. <br />Thus the provisions of the Nebraska Statutory Power Of Attorney that was <br />signed and dated by Amy E. Folkers on 01-02-2014, which states that "this <br />power of attorney Is effective only upon a determination that I am <br />incapacitated" have been met. <br />Signature --Dr. Jennifer Brown, MD Date <br />Cheryl Larsen <br />12345 Wasatch Rd <br />Longmont,C0 80504 <br />729-818.8486 Cell <br />