A document substantially in the following form may be used to create a statutory form power of attorney that has the meaning and effect prescribed by this act.
State of West Virginia
STATUTORY FORM POWER OF ATTORNEY
This power of attorney authorizes another person (your agent) to make decisions concerning your property for you (the principal). Your agent will be able to make decisions and act with respect to your property (including your money) whether or not you are able to act for yourself. The meaning of authority over subjects listed on this form is explained in the Uniform Power of Attorney Act [insert citation].
This power of attorney does not authorize the agent to make health-care decisions for you.
You should select someone you trust to serve as your agent. Unless you specify otherwise, generally the agent's authority will continue until you die or revoke the power of attorney or the agent resigns or is unable to act for you.
Your agent is entitled to reasonable compensation unless you state otherwise in the special instructions. This form provides for designation of one agent. If you wish to name more than one agent you may name a coagent in the Special Instructions. Coagents are not required to act together unless you include that requirement in the Special Instructions. If your agent is unable or unwilling to act for you, your power of attorney will end unless you have named a successor agent. You may also name a second successor agent.
This power of attorney becomes effective immediately unless you state otherwise in the Special Instructions.
If you have questions about the power of attorney or the authority you are granting to your agent, you should seek legal advice before signing this form.
DESIGNATION OF AGENT
I __________________________ name the following person as my agent:
(Name of Principal)
Name of Agent: __________________________________________________
Agent's Telephone Number:_________________________________________
If my agent is unable or unwilling to act for me, I name as my successor agent:
Name of Successor Agent:_________________________________________
Successor Agent's Address:_________________________________________
Successor Agent's Telephone Number:________________________________
If my successor agent is unable or unwilling to act for me, I name as my second successor agent:
Name of Second Successor Agent:____________________________________
Second Successor Agent's Address:__________________________________
Second Successor Agent's Telephone Number:________________________
GRANT OF GENERAL AUTHORITY
I grant my agent and any successor agent general authority to act for me with respect to the following subjects as defined in the Uniform Power of Attorney Act [insert citation]:
(INITIAL each subject you want to include in the agent's general authority. If you wish to grant general authority over all of the subjects you may initial "All Preceding Subjects" instead of initialing each subject.)
(___) Real Property
(___) Tangible Personal Property
(___) Stocks and Bonds
(___) Commodities and Options
(___) Banks and Other Financial Institutions
(___) Operation of Entity or Business
(___) Insurance and Annuities
(___) Estates, Trusts, and Other Beneficial Interests
(___) Claims and Litigation
(___) Personal and Family Maintenance
(___) Benefits from Governmental Programs or Civil or Military Service
(___) Retirement Plans
(___) All Preceding Subjects
GRANT OF SPECIFIC AUTHORITY (OPTIONAL)
My agent MAY NOT do any of the following specific acts for me UNLESS I have INITIALED the specific authority listed below:
(CAUTION: Granting any of the following 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. INITIAL ONLY the specific authority you WANT to give your agent.)
(___) Create, amend, revoke, or terminate an inter vivos trust
(___) Make a gift, subject to the limitations of the West Virginia Uniform Power of Attorney Act and any special instructions in this power of attorney
(___) Create or change rights of survivorship
(___) Create or change a beneficiary designation
(___) Authorize another person to exercise the authority granted under this power of attorney
(___) Waive the principal's right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan
(___) Exercise fiduciary powers that the principal has authority to delegate
[(___) Disclaim or refuse an interest in property, including a power of appointment]
LIMITATION ON AGENT'S AUTHORITY
An agent that is not my ancestor, spouse or descendant MAY NOT use my property to benefit the agent or a person to whom the agent owes an obligation of support unless I have included that authority in the Special Instructions.
SPECIAL INSTRUCTIONS (OPTIONAL)
You may give special instructions on the following lines:
_________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ __________________________________________________________________________________________________________________________________ _________________________________________________________________
This power of attorney is effective immediately unless I have stated otherwise in the special instructions.
NOMINATION OF [CONSERVATOR OR GUARDIAN] (OPTIONAL)
If it becomes necessary for a court to appoint a [conservator or guardian] of my estate or [guardian] of my person, I nominate the following person(s) for appointment:
Name of Nominee for [conservator or guardian] of my estate:
_________________________________________________________________ Nominee's Address:_________________________________________________
Nominee's Telephone Number:________________________________________
Name of Nominee for [guardian] of my person:_______________________
Nominee's Telephone Number:_______________________________________
RELIANCE ON THIS POWER OF ATTORNEY
Any person, including my agent, may rely upon the validity of this power of attorney or a copy of it unless that person knows it has terminated or is invalid.
SIGNATURE AND ACKNOWLEDGMENT
Your Signature Date
Your Name Printed__________________________________________________
Your Telephone Number____________________________________________
State of ___________________________________
This document was acknowledged before me on ________________,
(Name of Principal)
_______________________________________________ (Seal, if any)
Signature of Notary
My commission expires: ________________________
[This document prepared by:_______________________________________]
IMPORTANT INFORMATION FOR 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 upon you legal duties that continue until you resign or the power of attorney is terminated or revoked. You must:
(1) Do what you know the principal reasonably expects you to do with the principal's property or, if you do not know the principal's expectations, act in the principal's best interest; act in good faith;
(2) Do nothing beyond the authority granted in this power of attorney; and
(3) Disclose your identity as an agent whenever you act for the principal by writing or printing the name of the principal and signing your own name as "agent" in the following manner:
(Principal's Name) (Your Signature) as Agent
Unless the special instructions in this power of attorney state otherwise, you must also:
(1) Act loyally for the principal's benefit;
(2) Avoid conflicts that would impair your ability to act in the principal's best interest;
(3) Act with care, competence and diligence;
(4) Keep a record of all receipts, disbursements and transactions made on behalf of the principal;
(5) Cooperate with any person that has authority to make health-care decisions for the principal to do what you know the principal reasonably expects or, if you do not know the principal's expectations, to act in the principal's best interest; and
attempt to preserve the principal's estate plan if you know the plan and preserving the plan is consistent with the principal's best interest.
Termination of Agent's Authority
You must stop acting on behalf of the principal if you learn of any event that terminates this power of attorney or your authority under this power of attorney. Events that terminate a power of attorney or your authority to act under a power of attorney include:
(1) Death of the principal;
(2) The principal's revocation of the power of attorney or your authority;
(3) The occurrence of a termination event stated in the power of attorney;
(4) The purpose of the power of attorney is fully accomplished; or
(5) If you are married to the principal, a legal action is filed with a court to end your marriage or for your legal separation, unless the Special Instructions in this power of attorney state that such an action will not terminate your authority.
Liability of Agent
The meaning of the authority granted to you is defined in the Uniform Power of Attorney Act [insert citation]. If you violate the Uniform Power of Attorney Act [insert citation] or act outside the authority granted, you may be liable for any damages caused by your violation.
The following optional form may be used by an agent to certify facts concerning a power of attorney:
AGENT'S CERTIFICATION AS TO THE VALIDITY OF POWER OF ATTORNEY AND AGENT'S AUTHORITY
State of _____________________________
I, _____________________________________________ (Name of Agent), [certify] under penalty of perjury that ______________________________(Name of Principal) granted me authority as an agent or successor agent in a power of attorney dated ______________.
I, further [certify] that to my knowledge:
(1) The Principal is alive and has not revoked the power of attorney or my authority to act under the power of attorney and the power of attorney and my authority to act under the power of attorney have not terminated;
(2) If the power of attorney was drafted to become effective upon the happening of an event or contingency, the event or contingency has occurred;
(3) If I was named as a successor agent, the prior agent is no longer able or willing to serve; and
_________________________________________________________________ _________________________________________________________________ _________________________________________________________________ (Insert other relevant statements)
SIGNATURE AND ACKNOWLEDGMENT
Agent's Signature Date
Agent's Name Printed ____________________________________________
Agent's Telephone Number_________________________________________
This document was acknowledged before me on _______________,
(Name of Agent)
_________________________________________ (Seal, if any)
Signature of Notary
My commission expires: ________________________
[This document prepared by:_____________________________________]
Note: WV Code updated with legislation passed through the 2016 Regular Session
The West Virginia Code Online is an unofficial copy of the annotated WV Code, provided as a convenience. It has NOT been edited for publication, and is not in any way official or authoritative.