New York State Bar Association
New York Statutory Short Form Power of Attorney, Eff. 6/13/21
1
POWER OF ATTORNEY
NEW YORK STATUTORY SHORT FORM
(a) CAUTION TO THE PRINCIPAL: Your Power of Attorney is an important document. As the
“principal,” you give the person whom you choose (your “agent”) authority to spend your money and
sell or dispose of your property during your lifetime without telling you. You do not lose your
authority to act even though you have given your agent similar authority.
When your agent exercises this authority, he or she must act according to any instructions you
have provided or, where there are no specific instructions, in your best interest. “Important
Information for the Agent” at the end of this document describes your agent’s responsibilities.
Your agent can act on your behalf only after signing the Power of Attorney before a notary
public.
You can request information from your agent at any time. If you are revoking a prior Power of
Attorney, you should provide written notice of the revocation to your prior agent(s) and to any third
parties who may have acted upon it, including the financial institutions where your accounts are
located.
You can revoke or terminate your Power of Attorney at any time for any reason as long as you
are of sound mind. If you are no longer of sound mind, a court can remove an agent for acting
improperly.
Your agent cannot make health care decisions for you. You may execute a “Health Care
Proxy” to do this.
The law governing Powers of Attorney is contained in the New York General Obligations Law,
Article 5, Title 15. This law is available at a law library, or online through the New York State Senate
or Assembly websites, www.nysenate.gov or www.nyassembly.gov.
If there is anything about this document that you do not understand, you should ask a lawyer of
your own choosing to explain it to you.
(b) DESIGNATION OF AGENT(S):
I, ___________________________
_____________________________
(name of principal)
hereby appoint:
(address of principal)
_____________________________
_____________________________
(name of agent)
(address of agent)
_____________________________
_____________________________
(name of second agent)
(address of second agent)
as my agent(s).
New York State Bar Association
New York Statutory Short Form Power of Attorney, Eff. 6/13/21
2
If you designate more than one agent above and you do not initial the statement below, they must act
together.
( ) My agents may act SEPARATELY.
(c) DESIGNATION OF SUCCESSOR AGENT(S): (OPTIONAL)
If any agent designated above is unable or unwilling to serve, I appoint as my successor agent(s):
_________________________
________________________
(name of successor agent)
(address of successor agent)
_________________________
_________________________
(name of second successor agent),
(address of second successor agent)
If you do not initial the statement below, successor agents designated above must act together.
( ) My successor agents may act SEPARATELY.
You may provide for specific succession rules in this section. Insert specific succession provisions here:
(d) This POWER OF ATTORNEY shall not be affected by my subsequent incapacity unless I have
stated otherwise below, under “Modifications”.
(e) This POWER OF ATTORNEY DOES NOT REVOKE any Powers of Attorney previously
executed by me unless I have stated otherwise below, under “Modifications.”
(f) GRANT OF AUTHORITY:
To grant your agent some or all of the authority below, either
(1) Initial the bracket at each authority you grant, or
(2) Write or type the letters for each authority you grant on the blank line at (P), and
initial the bracket at (P). If you initial (P), you do not need to initial the other lines.
I grant authority to my agent(s) with respect to the following subjects as defined in sections 5-1502A
through 5-1502N of the New York General Obligations Law:
( ) (A) real estate transactions;
( ) (B) chattel and goods transactions;
( ) (C) bond, share, and commodity transactions;
( ) (D) banking transactions;
( ) (E) business operating transactions;
( ) (F) insurance transactions;
( ) (G) estate transactions;
New York State Bar Association
New York Statutory Short Form Power of Attorney, Eff. 6/13/21
3
( ) (H) claims and litigation;
( ) (I) personal and family maintenance: If you grant your agent this authority, it will allow the agent to
make gifts that you customarily have made to individuals, including the agent, and charitable
organizations. The total amount of all such gifts in any one calendar year cannot exceed five
thousand dollars;
( ) (J) benefits from governmental programs or civil or military service;
( ) (K) financial matters related to health care; records, reports, and statements;
( ) (L) retirement benefit transactions;
( ) (M) tax matters;
( ) (N) all other matters;
( ) (O) full and unqualified authority to my agent(s) to delegate any or all of the foregoing powers to
any person or persons whom my agent(s) select;
( ) (P) EACH of the matters identified by the following letters ______________________________.
You need not initial the other lines if you initial line (P).
(g) CERTAIN GIFT TRANSACTIONS: (OPTIONAL)
In order to authorize your agent to make gifts in excess of an annual total of $5,000 for all gifts
described in (I) of the grant of authority section of this document (under personal and family maintenance),
and/or to make changes to interest in your property, you must expressly grant that authorization in the
Modifications section below. If you wish to authorize your agent to make gifts to himself or herself, you
must expressly grant such authorization in the Modifications section below. Granting such authority to your
agent gives your agent the authority to take actions which could significantly reduce your property and/or
change how your property is distributed at your death. Your choice to grant such authority should be
discussed with a lawyer.
( ) I grant my agent authority to make gifts in accordance with the terms and conditions of the
Modifications that supplement this Statutory Power of Attorney.
(h) MODIFICATIONS: (OPTIONAL)
In this section, you may make additional provisions, including, but not limited to, language to limit
or supplement authority granted to your agent, language to grant your agent the specific authority to make
gifts to himself of herself, and /or language to grant your agent the specific authority to make other gift
transactions and/or changes to interests in your property. Your agent is entitled to be reimbursed from your
assets for reasonable expenses incurred on your behalf. In this section, you may make additional provisions
if you ALSO wish your agent(s) to be compensated from your assets for services rendered on your behalf,
and you may define “reasonable compensation.”
(i) DESIGNATION OF MONITOR(S): (OPTIONAL)
If you wish to appoint monitor(s), initial and fill in the section below:
( ) I wish to designate ____________________, whose address(es) is (are) ______________________,
as monitor(s). Upon the request of the monitor(s), my agent(s) must provide the monitor(s) with a copy of
the power of attorney and a record of all transactions done or made on my behalf. Third parties holding
records of such transactions shall provide the records to the monitor(s) upon request.
New York State Bar Association
New York Statutory Short Form Power of Attorney, Eff. 6/13/21
4
(j) COMPENSATION OF AGENT(S):
Your agent is entitled to be reimbursed from your assets for reasonable expenses incurred on your
behalf. If you ALSO wish your agent(s) to be compensated from your assets for services rendered on your
behalf, and/or you wish to define “reasonable compensation”, you may do so above, under "Modifications".
(k) ACCEPTANCE BY THIRD PARTIES:
I agree to indemnify the third party for any claims that may arise against the third party because of
reliance on this Power of Attorney. I understand that any termination of this Power of Attorney, whether the
result of my revocation of the Power of Attorney or otherwise, is not effective as to a third party until the
third party has actual notice or knowledge of the termination.
(l) TERMINATION:
This Power of Attorney continues until I revoke it or it is terminated by my death or other event
described in section 5-1511 of the General Obligations Law.
Section 5-1511 of the General Obligations Law describes the manner in which you may revoke
your Power of Attorney, and the events which terminate the Power of Attorney.
(m) SIGNATURE AND ACKNOWLEDGMENT:
In Witness Whereof I have hereunto signed my name on _____________, 20__
PRINCIPAL signs here: ====> ______________________________________
STATE OF NEW YORK )
) ss:
COUNTY OF ____________)
On the ____ day of _________, 20__, before me, the undersigned, personally appeared
_________________________, personally known to me or proved to me on the basis of satisfactory
evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me
that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the
individual, or the person upon behalf of which the individual acted, executed the instrument.
Notary Public
(n) SIGNATURE OF WITNESSES:
By signing as a witness, I acknowledge that the principal signed the Power of Attorney in my
presence and in the presence of the other witness, or that the principal acknowledged to me that the
principal’s signature was affixed by him or her or at his or her direction. I also acknowledge that the
principal has stated that this Power of Attorney reflects his or her wishes and that he or she has signed it
voluntarily. I am not named herein as an agent or as a permissible recipient of gifts.
_______________________________
_______________________________
Signature of Witness 1
Signature of Witness 2
New York State Bar Association
New York Statutory Short Form Power of Attorney, Eff. 6/13/21
5
_______________________________
_______________________________
Date
Date
_______________________________
_______________________________
Print name
Print name
_______________________________
_______________________________
Address
Address
_______________________________
_______________________________
City, State, Zip Code
City, State, Zip Code
(o) IMPORTANT INFORMATION FOR THE AGENT:
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 on you legal responsibilities that continue
until you resign or the Power of Attorney is terminated or revoked. You must:
(1) act according to any instructions from the principal, or, where there are no instructions, in the
principal's best interest;
(2) avoid conflicts that would impair your ability to act in the principal's best interest;
(3) keep the principal's property separate and distinct from any assets you own or control, unless
otherwise permitted by law;
(4) keep a record of all transactions conducted for the principal or keep all receipts of payments and
transactions conducted for the principal; and
(5) disclose your identity as an agent whenever you act for the principal by writing or printing the
principal's name and signing your own name as "agent" in either of the following manners:
(Principal's Name) by (Your Signature) as Agent, or (your signature) as Agent for (Principal's
Name).
You may not use the principal's assets to benefit yourself or anyone else or make gifts to yourself or
anyone else unless the principal has specifically granted you that authority in the modifications section of
this document or a Non-Statutory Power of Attorney. If you have that authority, you must act according to
any instructions of the principal or, where there are no such instructions, in the principal's best interest.
You may resign by giving written notice to the principal and to any co-agent, successor agent, monitor
if one has been named in this document, or the principal's guardian if one has been appointed. If there is
anything about this document or your responsibilities that you do not understand, you should seek legal
advice.
Liability of agent: The meaning of the authority given to you is defined in New York's General
Obligations Law, Article 5, Title 15. If it is found that you have violated the law or acted outside the
authority granted to you in the Power of Attorney, you may be liable under the law for your violation.
New York State Bar Association
New York Statutory Short Form Power of Attorney, Eff. 6/13/21
6
(p) AGENT'S SIGNATURE AND ACKNOWLEDGMENT OF APPOINTMENT:
It is not required that the principal and the agent(s) sign at the same time, nor that multiple agents
sign at the same time.
I/we, _________________________, have read the foregoing Power of Attorney. I am/we are the
person(s) identified therein as agent(s) for the principal named therein.
I/we acknowledge my/our legal responsibilities.
In Witness Whereof I have hereunto signed my name on ________________________ 20__
Agent(s) sign(s) here: ==> ____________________________________________
==> ____________________________________________
STATE OF NEW YORK )
) ss:
COUNTY OF ___________ )
On the _____ day of ___________, 20__, before me, the undersigned, personally appeared
____________________, personally known to me or proved to me on the basis of satisfactory evidence to
be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she
executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the
person upon behalf of which the individual acted, executed the instrument.
Notary Public
(q) SUCCESSOR AGENT’S SIGNATURE AND ACKNOWLEDGMENT OF APPOINTMENT:
It is not required that the principal and the SUCCESSOR agent(s), if any, sign at the same time, nor
that multiple SUCCESSOR agents sign at the same time. Furthermore, successor agents can not use this
power of attorney unless the agent(s) designated above is/are unable or unwilling to serve.
I/we, _________________________, have read the foregoing Power of Attorney. I am/we are the
person(s) identified therein as SUCCESSOR agent(s) for the principal named therein.
In Witness Whereof I have hereunto signed my name on ________________________ 20__
Successor Agent(s) sign(s) here: ==> ____________________________________________
==> ___________________________________________
New York State Bar Association
New York Statutory Short Form Power of Attorney, Eff. 6/13/21
7
_
STATE OF NEW YORK )
) ss:
COUNTY OF ____________ )
On the _____ day of __________, 20___, before me, the undersigned, personally appeared
___________________, personally known to me or proved to me on the basis of satisfactory evidence to be
the individual whose name is subscribed to the within instrument and acknowledged to me that he/she
executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the
person upon behalf of which the individual acted, executed the instrument.
Notary Public
