New York State Bar Association
Statutory Short Form Durable Power of Attorney, 7/28/09 

Power of Attorney New York Statutory Short Form

(a) CAUTION TO THE PRINCIPAL: Your Power of Attorney is an important document. As the "principal," you give the person whom you choose (your "agent") authority to spend your money and sell or dispose of your property during your lifetime without telling you. You do not lose your authority to act even though you have given your agent similar authority. 
When your agent exercises this authority, he or she must act according to any instructions you have provided or, where there are no specific instructions, in your best interest. "Important Information for the Agent" at the end of this document describes your agent's responsibilities.
Your agent can act on your behalf only after signing the Power of Attorney before a notary public.
You can request information from your agent at any time. If you are revoking a prior Power of Attorney by executing this Power of Attorney, you should provide written notice of the revocation to your prior agent(s) and to the financial institutions where your accounts are located.
You can revoke or terminate your Power of Attorney at any time for any reason as long as you are of sound mind. If you are no longer of sound mind, a court can remove an agent for acting improperly.
Your agent cannot make health care decisions for you. You may execute a "Health Care Proxy" to do this.
The law governing Powers of Attorney is contained in the New York General Obligations Law, Article 5, Title 15. This law is available at a law library, or online through the New York State Senate or Assembly websites, www.senate.state.ny.us or www.assembly.state.ny.us.
If there is anything about this document that you do not understand, you should ask a lawyer of your own choosing to explain it to you.

(b) DESIGNATION OF AGENT(S):
I, _________________________________________________, hereby appoint:
[name and address of principal]
____________________________________________________ as my agent(s)
[name(s) and address(es) of agent(s)] 

If you designate more than one agent above, they must act together unless you initial the statement below. 
(___) My agents may act SEPARATELY.
(c) DESIGNATION OF SUCCESSOR AGENT(S): (OPTIONAL)
If every agent designated above is unable or unwilling to serve, I appoint as my successor agent(s):
________________________________________________
________________________________________________
[name(s) and address(es) of successor agent(s)]

Successor agents designated above must act together unless you initial the statement below. 
(___) My successor agents may act SEPARATELY. 
(d) This POWER OF ATTORNEY shall not be affected by my subsequent incapacity unless I have stated otherwise below, under "Modifications". 
(e) This POWER OF ATTORNEY REVOKES any and all prior Powers of Attorney executed by me unless I have stated otherwise below, under "Modifications".
If you are NOT revoking your prior Powers of Attorney, and if you are granting the same authority in two or more Powers of Attorney, you must also indicate under "Modifications" whether the agents given these powers are to act together or separately.
(f) GRANT OF AUTHORITY:
To grant your agent some or all of the authority below, either (1) Initial the bracket at each authority you grant, or (2) Write or type the letters for each authority you grant on the blank line at (P), and initial the bracket at (P). If you initial (P), you do not need to initial the other lines.
I grant authority to my agent(s) with respect to the following subjects as defined in sections 5-1502A through 5-1502N of the New York General Obligations Law: 
(___)	(A)	real estate transactions;
(___)	(B)	chattel and goods transactions;
(___)	(C)	bond, share, and commodity transactions;
(___)	(D)	banking transactions;
(___)	(E)	business operating transactions;
(___)	(F)	insurance transactions;
(___)	(G)	estate transactions; 
(___)	(H)	claims and litigation;
(___)	(I)	personal and family maintenance;
(___)	(J)	benefits from governmental programs or civil or military service;
(___)	(K)	health care billing and payment matters; records, reports, and statements;
(___)	(L)	retirement benefit transactions;
(___)	(M)	tax matters;
(___)	(N)	all other matters;
(___)	(O)	full and unqualified authority to my agent(s) to delegate any or all of the foregoing
powers to any person or persons whom my agent(s) select;
(___)	(P)	EACH of the matters identified by the following letters      
                        	_________________________________________________
You need not initial the other lines if you initial line (P).

(g) MODIFICATIONS: (OPTIONAL) 
In this section, you may make additional provisions, including language to limit or supplement authority granted to your agent. However, you cannot use this Modifications section to grant your agent authority to make major gifts or changes to interests in your property. If you wish to grant your agent such authority, you MUST complete the Statutory Major Gifts Rider.
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(h) MAJOR GIFTS AND OTHER TRANSFERS: STATUTORY MAJOR GIFTS RIDER (OPTIONAL)
In order to authorize your agent to make major gifts and other transfers of your property, you must initial the statement below and execute a Statutory Major Gifts Rider at the same time as this instrument. Initialing the statement below by itself does not authorize your agent to make major gifts and other transfers. The preparation of the Statutory Major Gifts Rider should be supervised by a lawyer.
(___) (SMGR) I grant my agent authority to make major gifts and other transfers of my property, in accordance with the terms and conditions of the Statutory Major Gifts Rider that supplements this Power of Attorney.

(i) DESIGNATION OF MONITOR(S): (OPTIONAL)
I wish to designate _____________________________________________________,
whose address(es) is (are) _________________________________________________, as monitor(s). 
Upon the request of the monitor(s), my agent(s) must provide the monitor(s) with a copy of the Power of Attorney and a record of all transactions done or made on my behalf. Third parties holding records of such transactions shall provide the records to the monitor(s) upon request. 

(j) COMPENSATION OF AGENT(S): (OPTIONAL)
Your agent is entitled to be reimbursed from your assets for reasonable expenses incurred on your behalf. If you ALSO wish your agent(s) to be compensated from your assets for services rendered on your behalf, initial the statement below. If you wish to define "reasonable compensation", you may do so above, under "Modifications". 
(___) My agent(s) shall be entitled to reasonable compensation for services rendered. 

(k) ACCEPTANCE BY THIRD PARTIES: I agree to indemnify the third party for any claims that may arise against the third party because of reliance on this Power of Attorney. I understand that any termination of this Power of Attorney, whether the result of my revocation of the Power of Attorney or otherwise, is not effective as to a third party until the third party has actual notice or knowledge of the termination.

(l) TERMINATION: This Power of Attorney continues until I revoke it or it is terminated by my death or other event described in section 5-1511 of the General Obligations Law.
Section 5-1511 of the General Obligations Law describes the manner in which you may revoke your Power of Attorney, and the events which terminate the Power of Attorney.

(m) SIGNATURE AND ACKNOWLEDGMENT: 
In Witness Whereof I have hereunto signed my name on _____________________, 20___.
PRINCIPAL signs here: ==>__________________________________________ 

STATE OF NEW YORK	    )
    ) ss.:
COUNTY OF	 _____________ )

On the ________ day of _________ , in the year _______, before me, the undersigned, a Notary Public in and for said state, personally appeared __________________________________ , personally known to me or proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the person or the entity upon behalf of which the person acted, executed the instrument.

			Notary Public

(n) IMPORTANT INFORMATION FOR THE AGENT:
When you accept the authority granted under this Power of Attorney, a special legal relationship is created between you and the principal. This relationship imposes on you legal responsibilities that continue until you resign or the Power of Attorney is terminated or revoked. You must:
(1)	act according to any instructions from the principal, or, where there are no instructions,   in the principal's best interest;
(2)		avoid conflicts that would impair your ability to act in the principal's best interest;
(3)	keep the principal's property separate and distinct from any assets you own or control,    unless otherwise permitted by law;
(4)		keep a record or all receipts, payments, and transactions conducted for the principal; and
(5)	disclose your identity as an agent whenever you act for the principal by writing or    printing the principal's name and signing your own name as "agent" in either of the    following manner: (Principal's Name) by (Your Signature) as Agent, or (your signature) as Agent for (Principal's Name).
You may not use the principal's assets to benefit yourself or give major gifts to yourself or anyone else unless the principal has specifically granted you that authority in this Power of Attorney or in a Statutory Major Gifts Rider attached to this Power of Attorney. If you have that authority, you must act according to any instructions of the principal or, where there are no such instructions, in the principal's best interest. You may resign by giving written notice to the principal and to any co-agent, successor agent, monitor if one has been named in this document, or the principal's guardian if one has been appointed. If there is anything about this document or your responsibilities that you do not understand, you should seek legal advice. 
Liability of agent:
The meaning of the authority given to you is defined in New York's General Obligations Law, Article 5, Title 15. If it is found that you have violated the law or acted outside the authority granted to you in the Power of Attorney, you may be liable under the law for your violation.

(o) AGENT'S SIGNATURE AND ACKNOWLEDGMENT OF APPOINTMENT: It is not required that the principal and the agent(s) sign at the same time, nor that multiple agents sign at the same time.
I/we  _________________________________________________, have read the foregoing Power of Attorney. I am/we are the person(s) identified therein as agent(s) for the principal named therein.
I/we acknowledge my/our legal responsibilities.
Agent(s) sign(s) here:=>___________________________   _______________________________

STATE OF NEW YORK	)
) ss.:
COUNTY OF	 ___________)
On the __________day of _______________ , in the year _______, before me, the undersigned, a Notary Public in and for said state, personally appeared _________________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the person or the entity upon behalf of which the person acted, executed the instrument.
								
			Notary Public

STATE OF NEW YORK	)
) ss.:
COUNTY OF	 ___________ )
On the ________ day of ________________, in the year ________, before me, the undersigned, a Notary Public in and for said state, personally appeared _________________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the person or the entity upon behalf of which the person acted, executed the instrument.
								
			Notary Public

2008 N.Y. Laws ch. 644, § 19, 5-1513; 2009 N.Y. Laws ch. 4 (amending effective date from March 1, 2009 to September 1, 2009).