I, [name of principal], of [city], County, State of , appoint [name of attorney in fact] of [street address], [city], [County], State of , as my attorney in fact to act in my place for the purposes of [describe purpose].

I further grant to my attorney in fact full authority to act in any manner both proper and necessary to the exercise of the foregoing powers, including the full power of substitution and revocation and ratify every act that [he][she] may lawfully perform in exercising those powers.

This power of attorney will become effective on [date] and will terminate on [date]; provided, however, that this Special Power of Attorney is revocable by my at any time.

Executed on [date], at [city], [state].

ACKNOWLEDGMENT

State of ___________________

County of _________________

On [date], before me, ________________________ [name and title of officer taking acknowledgment], personally appeared ________________________ [name(s) of person(s) signing instrument], __________________ [personally known to me or proved to me on the basis of satisfactory evidence] to be the person[s] whose name[s] _______________ [is or are] subscribed to the within instrument and acknowledged to me that _________________ [he or she or they] executed the same in ____________________ [his or heror their] authorized _____________ [capacity or capacities], and that by ___________________ [his or her or their] signature[s] on the instrument the person[s], or the entity upon behalf of which the person[s] acted, executed the instrument.

WITNESS my hand and official seal.

Signature [Seal]