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202606662 <br />Surrogate Decision Making in Nebraska Nebraska State Unit on Aging <br />Nebraska Power of Attorney <br />DESIGNATION OF AGENT <br />1, Th nct S • T-1 i rci (your name) name the following person as my agent <br />(Individual with power of attorney): -t' <br />Agent: An .S a. R R. �/ aA9 <br />Address: <br />d9 s /3.'4 5 - (81Z 3 <br />Phone Number: 1.102 — 3 05-13 7 'i <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 0Yes or ❑No AND initial for each of the subjects that follow. These subjects represent those you <br />may want to include in the agentb general authority. If you wish to grant general authority over all of the <br />subjects you may check D Yes for "All Preceding Subjects" AND initial that line instead of checking each <br />subject.) <br />Check one: Initials: <br />❑Yes No Real Property <br />OYes No Tangible Personal Property <br />❑Yes No Stocks and Bonds <br />MLTC-P84 (99009) 2/21 <br />