STATE OF ARKANSAS ) ARKANSAS STATUTORY FORM

) POWER OF ATTORNEY
COUNTY OF [COUNTY] )

I. DESIGNATION OF AGENT

I, [CLIENT], of the City of [CITY], County of [COUNTY], State of Arkansas, hereby

appoint [NAME OF AGENT], who resides at [FULL ADDRESS OF AGENT] and whose
telephone number is [AGENT’S PHONE NUMBER] as my true and lawful agent and
attorney-in-fact.

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

[SUCCESSOR AGENT NAME], who resides at [FULL ADDRESS] and whose telephone
number is [PHONE NUMBER].

If my successor agent is unable or unwilling to act for me, I name as my second successor agent
[NAME OF SECOND SUCCESSOR], who resides at [FULL ADDRESS] and whose telephone
number is [PHONE NUMBER].

II. GRANT OF GENERAL AUTHORITY

I grant my agent and any successor agent general authority to act for me with respect to the
following subjects as defined in the Uniform Power of Attorney Act, Arkansas Code Title 28,
Chapter 68: [THE CLIENT HAS THE OPTION OF SELECTING THE FOLLOWING:
Real Property; Tangible Personal Property; Stocks and Bonds; Commodities and Options; Banks
and Other Financial Institutions; Operation of Entity or Business; Insurance and Annuities;
Estates, Trusts, and Other Beneficial Interests; Claims and Litigation; Personal and Family
Maintenance; Benefits from Governmental Programs or Civil or Military Service; Retirement
Plans; Taxes].
III. GRANT OF SPECIFIC AUTHORITY [OPTIONAL]
My agent is granted authority do the following specific acts for me: [THE CLIENT HAS THE
OPTION OF SELECTING THE FOLLOWING, ANYTHING NOT SELECTED WILL
GO DOWN TO NEXT SECTION, “LIMITATION ON AGENT’S AUTHORITY”:
Amend, revoke, or terminate an inter vivos trust;
Make a gift, subject to the limitations of Ark. Code Ann. § 28-68-217 of the Uniform Power
of Attorney Act and any special instructions in this power of attorney;
Create or change rights of survivorship;
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 Create or change a beneficiary designation;
Authorize another person to exercise the authority granted under this power of attorney;
Waive the principal's right to be a beneficiary of a joint and survivor annuity, including a
survivor benefit under a retirement plan;
Exercise fiduciary powers that the principal has authority to delegate.]

IV. LIMITATION ON AGENT'S AUTHORITY

My agent MAY NOT do any of the following specific acts for me: [THESE ARE THE ITEMS
THAT CLIENT DID NOT SELECT TO GRANT AGENT AUTHORITY TO DO, IF
NONE, THEN ONLY THE LAST PARAGRAPH WILL BE IN PLACE:
Amend, revoke, or terminate an inter vivos trust;
Make a gift, subject to the limitations of Ark. Code Ann. § 28-68-217 of the Uniform Power
of Attorney Act and any special instructions in this power of attorney;
Create or change rights of survivorship;
Create or change a beneficiary designation;
Authorize another person to exercise the authority granted under this power of attorney;
Waive the principal's right to be a beneficiary of a joint and survivor annuity, including a
survivor benefit under a retirement plan;
Exercise fiduciary powers that the principal has authority to delegate.]

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 listed below.

V. SPECIAL INSTRUCTIONS

[CLIENT CAN LIST ANY SPECIAL INSTRUCTIONS HERE]

[ALSO, CLIENT HAS OPTION OF SELECTING ONE OF THE FOLLOWING,

HAVE THESE ITEMS IN BOLD, IF POSSIBLE: This power of attorney is effective
immediately and shall not be affected by my subsequent disability or incapacity.] OR
[This power of attorney shall become effective only upon my disability or incapacity
and shall endure through such events.]

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[IF OPTION # 2 IS SELECTED, THEN THE FOLLOWING LANGUAGE NEEDS
TO BE IN PLACE: For purposes of determining my incapacity, I shall be deemed to be
incapacitated in the event my agent shall come into possession of either of the following:

(1) A valid court order appointing a guardian or conservator of my person or

estate, or otherwise holding me to be legally incapacitated to act on my own behalf; or

(2) A duly executed and acknowledged written certificate of a licensed

physician certifying that such physician has examined me and has concluded that by reason
of accident, physical or mental illness, deterioration, or other similar cause, I have become
incapacitated and unable to act rationally and prudently in financial matters.

Such incapacity shall be deemed to continue until such court order or certificate have
become inapplicable or have been revoked. A physician’s certificate may be revoked by a
similar certificate to the effect that I am no longer incapacitated, executed either (i) by the
originally certifying physician or (ii) by another licensed physician.

I hereby authorize the physician(s) who examine me for the purposes of determining my
incapacity to disclose my physical or mental condition to the person(s) named herein as
my agent and attorney-in-fact. This authorization is intended to comply with the
requirements of the Health insurance Portability and Accountability Act of 1996 (HIPAA),
HIPAA regulations, and other State and Federal laws and regulations that may create a
right of privacy in the health information approved to be disclosed by this authorization.]

VI. NOMINATION OF GUARDIAN [THIS IS OPTIONAL & THE HEADING

SHOULD BE REMOVED IF CLIENT ELECTS NOT TO NOMINATE A
GUARDIAN]
[If it becomes necessary for a court to appoint a guardian of my estate or guardian of my person,
I nominate the following person for appointment [FULL NAME], who resides at [FULL
ADDRESS], and whose phone number is [PHONE NUMBER].

VII. RELIANCE ON THIS POWER OF ATTORNEY

Any person, including my agent, may rely upon the validity of this power of attorney or a copy
of it unless that person knows it has terminated or is invalid.

DATED this _______ day of __________________, 20___

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 _____________________________________
[FULL NAME OF CLIENT]
[FULL ADDRESS OF CLIENT]
[PHONE NUMBER OF CLIENT]

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 ACKNOWLEDGMENT

STATE OF ARKANSAS )
)
COUNTY OF [COUNTY] )

On this ______ day of_____________, 20___, before me, the undersigned officer,
personally appeared [NAME OF CLIENT], known to me (or satisfactorily proven) to be
the person who subscribed to the within instrument and acknowledged that he/she executed
the same for the consideration, use and purposes therein contained.

IN WITNESS WHEREOF, I have hereunto set my hand and seal this __ day of
_________, 20___.

________________________________
NOTARY PUBLIC
My Commission Expires:

___________________
(S E A L)

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IMPORTANT INFORMATION FOR PRINCIPAL
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, Arkansas Code Title 28, Chapter 68.

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 is 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 co-agent in the Special Instructions. Co-agents 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 questions about the power of attorney or the authority you are granting to your
agent, you should seek legal advice before signing this form.

IMPORTANT INFORMATION FOR AGENT

Agent's Duties
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 upon you legal duties that
continue until you resign or the power of attorney is terminated or revoked. You must:
(1) do what you know the principal reasonably expects you to do with the principal's
property or, if you do not know the principal's expectations, act in the principal's best interest;
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 (2) act in good faith;
(3) do nothing beyond the authority granted in this power of attorney; and
(4) disclose your identity as an agent whenever you act for the principal by writing or
printing the name of the principal and signing your own name as "agent" in the following
manner:

(Principal's Name) by (Your Signature) as Agent

Unless the Special Instructions in this power of attorney state otherwise, you must also:
(1) act loyally for the principal's benefit;
(2) avoid conflicts that would impair your ability to act in the principal's best interest;
(3) act with care, competence, and diligence;
(4) keep a record of all receipts, disbursements, and transactions made on behalf of the
principal;
(5) cooperate with any person that has authority to make health-care decisions for the
principal to do what you know the principal reasonably expects or, if you do not know the
principal's expectations, to act in the principal's best interest; and
(6) attempt to preserve the principal's estate plan if you know the plan and preserving the
plan is consistent with the principal's best interest.
Termination of Agent's Authority
You must stop acting on behalf of the principal if you learn of any event that terminates this
power of attorney or your authority under this power of attorney. Events that terminate a power
of attorney or your authority to act under a power of attorney include:
(1) death of the principal;
(2) the principal's revocation of the power of attorney or your authority;
(3) the occurrence of a termination event stated in the power of attorney;
(4) the purpose of the power of attorney is fully accomplished; or
(5) if you are married to the principal, a legal action is filed with a court to end your
marriage, or for your legal separation, unless the Special Instructions in this power of attorney
state that such an action will not terminate your authority.
Liability of Agent

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The meaning of the authority granted to you is defined in the Uniform Power of Attorney Act,
Arkansas Code Title 28, Chapter 68. If you violate the Uniform Power of Attorney Act,
Arkansas Code Title 28, Chapter 68, or act outside the authority granted, you may be liable for
any damages caused by your violation.
If there is anything about this document or your duties that you do not understand, you should
seek legal advice.

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