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202506490 <br />Surrogate Decision Making in Nebraska <br />Nebraska State Unit on Aging <br />Nebraska Power of Attorney <br />DESIGNATION OF A ENT <br />I,Ca <br />(individual with power of attorney): <br />(your name) name the following person as my agent <br />Agent: 1.-t.11"t <br />Address: 120 p t&)O i 4 Cali( JLa&I , (%0-s <br />Phone Number: 3o - 3 ' 3- L ' 2 . <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: <br />Address: <br />Phone Number: <br />If my agent is unable or unwilling to act for me, I name as my second successor agent (OPTIONAL): <br />Name of Second Successor Agent: <br />Address: <br />Phone Number: <br />RELEASE OF INFORMATION <br />I agree to, authorize, and allow full release of information, by any governmental agency, business, <br />creditor, or third party who may have information pertaining to my assets or income, to my agent named <br />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 following <br />subjects (as defined in the Nebraska Uniform Power of Attorney Act): <br />(CHECK Ca Yes or Li No AND initial for each of the subjects that follow These subjects represent those you <br />m y want to include in the agent's general authority. If you wish to grant general authority over all of the <br />subjects you may check es for "All Preceding Subjects" AND initial that line instead of checking each <br />subject.) <br />Check one: Initials: <br />❑Yes D No Real Property <br />❑Yes ONo _ Tangible Personal Property <br />OYes 0No Stocks and Bonds <br />POLLARD, LINDA K <br />DOS: 9/12/1948 (76 yrs) Female <br />MRN: 801533066 Adm Date: 7/24/2025 <br />CqSN:JJ4003335326641 Unit: SFMC4PCU <br />INIII1I1IIIIJIII!lR[iII II <br />MLTC•P8.3 (99009) 2/21 <br />