Form Pa-1 - Special Power Of Attorney (Business, Estate, Or Trust) Page 2
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4AFFIRMATION OF WITNESS
I affirm that the principal appeared to be of sound mind and free from duress at the time this power of attorney
was signed, and that he/she affirmed that he/she was aware of the nature of this document and signed it
freely and voluntarily.
Print name of Witness
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Signature of Witness for person signing on Line 13
Date
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FOR USE BY NOTARY
State of ______________________________
County of ____________________________ , SS.
At ___________________________________
on the _______ day of ________________, 20_____
City
Day
Month
Year
personally appeared ________________________________ who acknowledged this Instrument signed by
Name from Line 11
him/her to be his/her free act and deed, and the free act and deed of ______________________________
Name from Line 1
Before me _________________________________
My Commission Expires: _____________________
ATTESTATION OF AGENT
I hereby attest that I accept appointment as agent for the principal and:
that I understand my duties under this power of attorney and under the law;
that I understand that I have a duty to act for the principal as to specified transactions or types of transac-
tions if expressly required to do so in this power of attorney;
that I hereby specifically acknowledge and accept such duties to act in signing this power of attorney;
in the case of such a duty to act, my agreement to act on behalf of the principal is enforceable against me
regardless of whether there is any consideration to support a contractual obligation;
that I understand and acknowledge in signing this power of attorney, that if I have been selected as agent
with the expectation that I have special skills or expertise I will use those skills on behalf of the principal.
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Signature of Agent (person on Line 3)
Date
Form PA-1(Bus.)
rev. 1/07
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Parent category: Legal