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202606662 <br />Surrogate Decision Making in Nebraska <br />DYes ❑No <br />DYes DNo <br />❑Yes ❑No <br />DYes D No <br />❑Yes DNo <br />DYes DNo <br />❑Yes DNo <br />❑Yes DNo <br />DYes DNo. <br />fes ❑ No <br />Commodities and Options <br />Banks and Other Financial Institutions <br />Operation of Entity or Business <br />Insurance and Annuities <br />Estates, Trusts, and Other Beneficial Interests Claims and Litigation <br />Personal and Family Maintenance <br />Benefits from Governmental Programs or Civil or Military Service <br />Retirement Plans <br />Taxes <br />All Preceding Subjects (includes all items listed above) <br />Nebraska State Unit on Aging <br />GRANT OF SPECIFIC AUTHORITY (OPTIONAL) <br />My agent MAY do any of the following specific acts for me IF I have CHECKED the specific authority <br />listed below: <br />(CAUTION: Granting any of the following will give your agent the authority to take actions that could <br />significantly reduce your property or change how your property is distributed at your death. CHECK YES <br />AND INITIAL ONLY the specific authority you WANT to give your agent. NOTE: If you do not mark yes <br />and initial the authority, the authority Is not granted.) <br />Check one: Initials: <br />DYes<lo 5)ck Create, amend, revoke, or terminate an inter vivos trust <br />❑ Yes(o 3 <br />DYesy f o aN <br />❑Yesjjio <br />OYes 12dIo <br />DYes&3 o <br />LZI s ❑No <br />OYes alCro <br />Make a gift, subject to the limitations of the Nebraska Uniform Power of <br />Attorney Act and any special instructions in this power of attorney <br />Create or change rights of survivorship <br />Create or change a beneficiary designation <br />Delegate to another person to exercise the authority granted under this <br />power of attorney <br />Waive the principal's right to be a beneficiary of a joint and survivor annuity, <br />including a survivor benefit under a retirement plan <br />Exercise fiduciary powers that the principal has authority to,.delegate <br />Renounce or disclaim an interest in property, including a power of appointment <br />LIMITATION ON AGENT'S AUTHORITY <br />If I did not check the "Power of Personal and Family Maintenance" or the "All Preceding Subjects" in the <br />Grant of General Authority above, my agent MAY NOT use my property to benefit themselves or anyone <br />they support except for those items listed below in the Special Instructions. <br />MLTC•F11-3 (99009) 2/21 <br />