N.y. Statutory Short Form Power Of Attorney Template Page 6
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7N.Y. Statutory Short Form Power of Attorney
Effective 09-01-09
State of _________________
County of _______________ ss.:
On the ____ day of _______________ in the year ______ before me, the undersigned, personally
appeared __________________________________, personally known to me or proved to me
on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to
the within instrument and acknowledged to me that he/she/they executed the same in
his/her/their capacity(ies), and that by his/her their signature(s) on the instrument, the
individual(s), or the person upon behalf of which the individual(s) acted, executed the
instrument.
________________________________________________
Signature and Office of individual taking acknowledgment
State of _________________
County of _______________ ss.:
On the ____ day of _______________ in the year ______ before me, the undersigned, personally
appeared __________________________________, personally known to me or proved to me
on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to
the within instrument and acknowledged to me that he/she/they executed the same in
his/her/their capacity(ies), and that by his/her their signature(s) on the instrument, the
individual(s), or the person upon behalf of which the individual(s) acted, executed the
instrument.
________________________________________________
Signature and Office of individual taking acknowledgment
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