DISTRICT OF COLUMBIA STATUTORY (FINANCIAL) POWER OF ATTORNEY

1. Your Information

Principal (Grantor)

What is your first name?

What is your middle name?

What is your last name? (please write your legal last name as shown in your identity documents) Address:

In which city do you live?

State/Province (e.g., DC):

What is your ZIP/Postal Code?

What is your phone number?

2. Designation of Agent

Agent

What is the name of the person you want to designate as your agent or representative in this financial power of attorney to?

First Name:

Middle Name (Optional):

Last Name:

City:

State/Province (e.g., DC):

ZIP/Postal Code:

Phone Number:

DESIGNATION OF SUCCESSOR AGENT [Optional]

If my agent is unable or unwilling to act for me, I name as my successor agent:

First Name:

Middle Name:

Last Name: Address:

City:

State:

Zip Code:

Telephone Number:

This section is optional. Leave blank if you do not wish to designate a successor agent.

DESIGNATION OF SECOND SUCCESSOR AGENT [Optional]

If my successor agent is unable or unwilling to act for me, I name as my second successor agent:

First Name:

Middle Name:

Last Name: Address:

City:

State:

Zip Code:

Telephone Number:

This section is optional. Leave blank if you do not wish to designate a second successor agent.

3. GRANT OF GENERAL AUTHORITY

Select the topics over which you want to grant your agent or representative authority to represent you, if you do not wish to grant a specific authority, do not select it

Please specify the car(s) or vehicle information:

GRANT OF SPECIFIC AUTHORITY [Optional]

My agent MAY NOT do any of the following specific acts for me UNLESS I have INITIALED the specific authority listed below:

CAUTION: Granting any of the following will give your agent the authority to take actions that could significantly reduce your property or change how your property is distributed at your death. INITIAL ONLY the specific authority you WANT to give your agent.

This section is optional. Leave blank if you do not wish to grant any specific authority.

13. NOMINATION OF CONSERVATOR [Optional]

If it becomes necessary for a court to appoint a conservator of my estate, I nominate the following person for appointment:

First Name:

Middle Name:

Last Name: Address:

City:

State:

Zip Code:

Telephone Number:

This section is optional. Leave blank if you do not wish to nominate a conservator.

14. NOMINATION OF GUARDIAN [Optional]

If it becomes necessary for a court to appoint a guardian of my person, I nominate the following person for appointment:

First Name:

Middle Name:

Last Name: Address:

City:

State:

Zip Code:

Telephone Number:

This section is optional. Leave blank if you do not wish to nominate a guardian.

LIMITATION ON AGENT'S AUTHORITY

An agent that is not my ancestor, spouse or descendant 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.

I understand this limitation.

5. Special Instructions

Special Instructions Please write any specific special instructions you want to add to this power of attorney (Optional)

These custom limits will be included in the final document, if provided.

6. Legal Agreement and Limitations

Review and Acknowledge

Please read and agree to the following information:

This power of attorney authorizes another person (your agent) to make decisions concerning your property for you (the principal). Your agent will be able to make decisions and act with respect to your property (including your money) whether or not you are able to act for yourself. The meaning of authority over subjects listed on this form is explained in the Uniform Power of Attorney Act of 2022 (D.C. Official Code § 21-2601.01 et seq.).

This power of attorney does not authorize the agent to make health care decisions for you. You should select someone you trust to serve as your agent. Unless you specify otherwise, generally the agent's authority will continue until you die or revoke the power of attorney or the agent resigns or is unable to act for you. Your agent may be entitled to reasonable compensation unless you state otherwise in the Special Instructions.

This form provides for designation of one agent. If you wish to name more than one agent you may name a coagent in the Special Instructions. Coagents are not required to act together unless you include that requirement in the Special Instructions. If your agent is unable or unwilling to act for you, your power of attorney will end unless you have named a successor agent. You may also name a second successor agent.

This power of attorney becomes effective immediately unless you state otherwise in the Special Instructions. If you have any questions about the power of attorney or the authority you are granting to your agent, you should seek legal advice before signing this form.

I have read and understood this.

DISTRICT OF COLUMBIA STATUTORY (FINANCIAL) POWER OF ATTORNEY (D.C. Official Code § 21-2601.01 et seq.)

1. Your Information

2. Designation of Agent

DESIGNATION OF SUCCESSOR AGENT [Optional]

DESIGNATION OF SECOND SUCCESSOR AGENT [Optional]

3. GRANT OF GENERAL AUTHORITY

GRANT OF SPECIFIC AUTHORITY [Optional]

13. NOMINATION OF CONSERVATOR [Optional]

14. NOMINATION OF GUARDIAN [Optional]

LIMITATION ON AGENT'S AUTHORITY

5. Special Instructions

6. Legal Agreement and Limitations

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