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Designation of Agent for After Death Arrangements
 
My Agent shall have full power and authority to act on my behalf, but only to the extent permitted by this Designation of Agent. 
 
I hereby grant to my Agent the full right, power, and authority to do every act, deed, and thing necessary or advisable to be done regarding the above power, as fully as I could do if personally present and acting.
 
My agent shall not be liable for any loss that results from a judgment error that was made in good faith. However, my agent shall be liable for willful misconduct or the failure to act in good faith while acting under the authority of this power of attorney.
 
(Print) I, ___________________________________________, of ______________________________ do hereby designate ___________________________________________________of ______________________________ as my Designated Agent.
Signature: ___________________________________________________________________Date: ____________________________
Address: _______________________________________________________________________________________________________
 

WITNESSES
I declare under penalty of perjury under the laws of the State of ____________________________________   that the person who signed or acknowledged this document is personally known to me to be the principal, or that the identity of the principal was proved to me by convincing evidence; that the principal signed or acknowledged this durable power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud, or undue influence; that I am not the person appointed as attorney in fact of this document; and that I am not the principal’s health care provider, an employee of the principal’s health care provider, the operator of a community care facility or a residential care facility for the elderly, nor an employee of an operator of a community care facility or residential care facility for the elderly.
 
I further declare under penalty of perjury under the laws of this State that, to the best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law.
                                                                                                                                                                                                                                                                                                
Witness 1 Signature: ____________________________________________________                                                                                     
Print name __________________________________________________ Date _____________________________
Address _________________________________________________________________
 
Witness 2 Signature: ____________________________________________________
Print name __________________________________________________ Date ______________________________
Address _________________________________________________________________