N.H. Rev. Stat. § 564-E:301 — NH Code / Title LVI / Chapter 564-E / Section 301
564-E:301 Statutory Form Power of Attorney.
Status: in_force

A document substantially in the following form may be used to create a power of attorney that is in compliance with the provisions of this chapter. It is not required that a document be substantially in the following form in order to create a power of attorney that is in compliance with the provisions of this chapter: NEW HAMPSHIRE STATUTORY POWER OF ATTORNEY INFORMATION CONCERNING THE POWER OF ATTORNEY THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT YOU SHOULD KNOW THESE IMPORTANT FACTS: Notice to the Principal: As the "Principal," you are using this Power of Attorney to grant power to another person (called the "Agent") to make decisions, including, but not limited to, decisions concerning your money, property, or both, and to use your money, property, or both on your behalf. If this Power of Attorney does not limit the powers that you give to your Agent, your Agent will have broad and sweeping powers to sell or otherwise dispose of your property, and to spend your money without advance notice to you or approval by you. Unless you have expressly provided otherwise in this Power of Attorney, your Agent will have these powers before you become incapacitated, and unless you have expressly provided otherwise in this Power of Attorney, your Agent will continue to have these powers after you become incapacitated. You have the right to retain this Power of Attorney and to release it later or to request that another person retain this Power of Attorney on your behalf and release it only if one or more conditions specified in advance by you are satisfied. You have the right to revoke or take back this Power of Attorney at any time, so long as you are of sound mind. If there is anything about this Power of Attorney that you do not understand, you should seek professional advice. Principal's Signature: Date: 1. DESIGNATION OF AGENT I, (Name of Principal), of (Address of Principal), name the following person as my agent: Name of Agent: Agent's Address: 2. DESIGNATION OF SUCCESSOR AGENT(S) (OPTIONAL) If my agent is unable or unwilling to act for me, I name the following person as my successor agent: Name of Successor Agent: Successor Agent's Address: If my successor agent is unable or unwilling to act for me, I name the following person as my second successor agent: Name of Second Successor Agent: Second Successor Agent's Address: 3. REVOCATION OF EXISTING POWERS OF ATTORNEY (Initial the following statement if it is your choice.) __________ This Power of Attorney revokes all existing powers of attorney, except for powers of attorney relating to health care, previously executed by me. 4. GRANT OF GENERAL AUTHORITY (Initial beside your choice of A or B, but not both.) __________ A. I grant my agent general authority to act for me in all matters, including, without limitation, all of the subjects enumerated in B below. __________ B. I grant my agent general authority over the following subjects: (Initial each subject you want to include in the agent's general authority.) __________ Real Property as defined in RSA 564-E:204 __________ Tangible Personal Property as defined in RSA 564-E:205 __________ Stocks and Bonds as defined in RSA 564-E:206 __________ Commodities and Options as defined in RSA 564-E:207 __________ Banks and Other Financial Institutions as defined in RSA 564-E:208 __________ Operation of Entity or Business as defined in RSA 564-E:209 __________ Insurance and Annuities as defined in RSA 564-E:210 __________ Estates, Trusts and Other Beneficial Interests as defined in RSA 564-E:211 __________ Claims and Litigation as defined in RSA 564-E:212 __________ Personal and Family Maintenance as defined in RSA 564-E:213 __________ Benefits from Governmental Programs or Civil or Military Service as defined in RSA 564-E:214 __________ Retirement Plans as defined in RSA 564-E:215 __________ Taxes as defined in RSA 564-E:216 __________ Digital Assets as defined in RSA 554-A:2(10) 5. GRANT OF SPECIFIC AUTHORITY (OPTIONAL) (Initial each subject you want to include in the agent's authority. CAUTION: As to some of the following subjects, granting your agent authority will give your agent the authority to take actions that could significantly reduce your property or change how your property is distributed at your death.) My agent MAY NOT do any of the following specific acts for me UNLESS I have INITIALED the specific authority listed below: __________ Create, amend, revoke, or terminate an inter vivos trust (If you have granted your agent the authority to create, amend, revoke, or terminate an inter vivos trust, then initial the following statement if it is your choice.) __________ My agent may create, amend, revoke, or terminate an inter vivos trust to benefit himself or herself or any individual to whom my agent owes a legal obligation of support. __________ Make a gift, subject to the limitations of RSA 564-E:217 (If you have granted your agent the authority to make a gift, then as to each of the following statements, initial beside it if it is your choice.) __________ My agent may make a gift, even if it will leave me without sufficient assets or income to provide for my care without relying on Medicaid, other public assistance or charity. __________ My agent may make a gift to himself or herself and to any individual to whom my agent owes a legal obligation of support. __________ Create or change rights of survivorship (If you have granted your agent the authority to create or change rights of survivorship, then initial the following statement if it is your choice.) __________ My agent may create or change rights of survivorship to benefit himself or herself or any individual to whom my agent owes a legal obligation of support. __________ Create or change a beneficiary designation (If you have granted your agent the authority to create or change a beneficiary designation, then initial the following statement if it is your choice.) __________ My agent may create or change a beneficiary designation to benefit himself or herself or any individual to whom my agent owes a legal obligation of support. __________ Reject, renounce, disclaim, release, or consent to a reduction in or modification of my share in, or a payment to me from, an estate, trust, or other beneficial interest, to benefit my agent or any individual to whom my agent owes a legal obligation of support __________ Delegate authority granted under this Power of Attorney to another person __________ Waive my right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan (If you have granted your agent the authority to waive your right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan, then initial the following statement if it is your choice.) __________ My agent may waive my right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan, to benefit himself or herself or any individual to whom my agent owes a legal obligation of support. __________ Exercise the fiduciary power(s) that I have the authority to delegate as specified in the "Special Instructions" in Paragraph 6 of this Power of Attorney __________ Exercise authority over the content of electronic communication sent or received by me pursuant to RSA 554-A:9 __________ Exercise authority with respect to intellectual property, including, without limitation, copyrights, contracts for payment of royalties, and trademarks 6. SPECIAL INSTRUCTIONS (OPTIONAL) (Here you may include special instructions. You may leave this Paragraph blank. You may attach additional pages as necessary.) 7. EFFECTIVE DATE AND AUTHORITY OF AGENT This Power of Attorney is effective immediately unless I have stated otherwise in the Special Instructions in Paragraph 6 of this Power of Attorney. An agent (including successor agent) named in this Power of Attorney will have no authority to act as my agent until he or she has signed and affixed to this Power of Attorney an acknowledgment that is substantially the same as the Acknowledgment at the end of this Power of Attorney. 8. GOVERNING LAW This Power of Attorney shall be governed by the laws of the State of New Hampshire. 9. RELIANCE ON THIS POWER OF ATTORNEY Any person, including my agent, may rely upon this Power of Attorney if it is acknowledged before a notary public or other individual authorized to take acknowledgments (or a copy of the acknowledged Power of Attorney), unless that person knows it is void, invalid, or terminated. SIGNATURE AND ACKNOWLEDGMENT (You must date and sign this Power of Attorney. If you are physically unable to sign, it may be signed by someone else writing your name, in your presence and at your express direction. This Power of Attorney must be acknowledged before a notary public or other individual authorized by law to take acknowledgments.) Principal's Signature: Principal's Printed Name: Principal's Address: Date: STATE OF NEW HAMPSHIRE COUNTY OF _________________________ The foregoing Power of Attorney was acknowledged before me on _________________________ , by _________________________ , known to me or satisfactorily proven to be the person named herein Signature of Notarial Officer: Title (and Rank): My commission expires: AGENT ACKNOWLEDGMENT Notice to Agent: You will have no authority to act as agent under this Power of Attorney until you sign and affix this acknowledgment to the Power of Attorney. I, ______________________________ , have read the attached power of attorney and am the person identified as the agent for the principal. I hereby acknowledge that when I act as agent I am given power under the power of attorney to make decisions about money, property, or both belonging to the principal, and to spend the principal's money, property, or both on the principal's behalf, in accordance with the terms of the power of attorney. When acting as agent, I have duties (called "fiduciary duties") to act in accordance with the principal's reasonable expectations to the extent actually known by me and, otherwise, in the principal's best interest, to act in good faith, and to act only within the scope of authority granted in the power of attorney, as well as other duties imposed by law to the extent not provided otherwise in the power of attorney. As an agent, I am not entitled to use the money or property for my own benefit or to make gifts to myself or others unless the power of attorney specifically gives me the authority to do so. As an agent, my authority under the power of attorney will end when the principal dies and I will not have authority to manage or dispose of any property or administer the estate of the principal. If I violate a fiduciary duty under the power of attorney, I may be liable for damages and may be subject to criminal prosecution. If there is anything about this power of attorney, or my duties under it, that I do not understand, I understand that I should seek professional advice. Agent's Signature: Date: