POWER OF ATTORNEY

BE IT KNOWN that I, ------------------------------ of -------------------------------------------------- the undersigned, being of sound mind and legal
capacity, do hereby make and appoint -------------------------, the
undersigned of ---------------------------------- as my true and lawful
attorney-in-fact.

Said attorney-in-fact shall have full power and authority to act in my name
and place and consistent with my best interest the following acts on my
behalf, as my attorney in his discretion deems necessary and advisable:
1. Demand from ------------------------- Bank of -------------------------------------- branch my transaction statements on account no.: A)----------------------, (B)----------------------- (C)------------------------- and
(D)----------------------.
2. Vet same statements of account(s).
3. Demand the correction of any errors thereto.
The authority herein shall include such incidental acts as are reasonably
required to carry out and perform the specific authorities granted herein.
This document shall be effective upon execution from --------------, 2013
and shall not be affected by my disability or mental incompetency, except as
may be provided by an applicable statute.

IN WITNESS WHEREOF, I have set my signature below

_______________________________________
Principal's Signature
______/______/_________
Date

Page 1 of 2

Agreed to and accepted by:

_______________________________________
Agent's Signature
______/______/_________
Date
WITNESSES:
We know the principal personally and we believe him/her to be at least 18
years of age and of sound mind. This document was signed in our presence.
The principal appears to be of sound mind, and to be making this
designation voluntarily, without duress, fraud or undue influence.
Witness 1:
Name _______________________________________________
Address _____________________________________________
Signature _______________________ Date ____/____/______
Witness 2:
Name _______________________________________________
Address _____________________________________________
Signature _______________________ Date ____/____/______
Subscribed and sworn to before me on this _____ day of
_________________, 20_____.
________________________________________
Notary's Signature and seal

Page 2 of 2