HomeMy WebLinkAboutAPPOIMENT & IDENTIFICATION OF AGENTr ,
JAN o ���� DURABLE POWER OF ATTORNEY OF DV
Permitting BEATRICE S. KUPIEC
s r. Lucie County, ' Lueee Com
KNOW ALL MEN BY THESE PRESENTS, that I, BEATRICE S. KUPIEC of MARTIN County, Florida, referred to
in this document as the "Principal," do hereby execute this document on the date set forth below as a durable power of
attorney pursuant to the Florida Power of Attorney Act, Florida Statutes, sections 709.2101 - 709.2402.
01. Appointment and Identification of Agents. I do hereby constitute and appoint the person(s) caned below,
each referred to in this document as an "Agent" or as an "Attorney in Fact," as my true and lawfuAgent and
Attorney in Fact to act for me and in my` name and stead for all purposes as stated hereinafter.
First Agent: KATHLEEN M. SULLIVAN, Friend, 20 Hodgdon Farm Lane, Newington, NH 03801, 603-988-2651
Second Agent: JOHN M. RILEY, JR., Friend,
If more than one Agent has been named above, then the following shall apply (initial one):
Each of the named Agents shall have authority to act on my behalf at all times and may exercise his or her
authority independently from the other Agent(s).
Only 1 Agent at a time shall have authority to act on my behalf at any one time. The above named persons
are to exercise their authority in the order named with only one having authority at any one time.
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My named Agents shall be disqualified from serving while any of the following are in effect:
if the Agent has resigned as agent, is deceased, or is incapacitated;
if the Agent is not legally qualified to serve;
if the Agent declines to serve; or,
if the Agent is my spouse and we be legally separated or divorced.
The applicable successor Agent may act only with written evidence which shows that the predecessor Agent(s)is/ are not
serving. Such evidence may include:
A. written resignation(s) of the predecessor Agent(s);
B. death certificates) of the predecessor Agent(s);
C. evidence of incapacity of the predecessor Agent(s) as provided in paragraph 06E below; or
D. a written statement by any Agent who has declined to serve.
Any person dealing with a successor Attorney in Fact or Agent may rely upon the statement of my successor Attorney in
Fact or Agent that such successor is entitled to exercise the powers granted in this instrument. Any prior -named Attorney
in Fact and Agent shall be estopped to deny the authority of my successor Attorney in Fact or Agent in dealings with any
third party on my behalf, and I shall be estopped to deny the authority of my Attomey in Fact or Agent and any successor
named herein as against any third party dealing with my Attorney in Fact or Agent in reliance upon this instrument.
02. Durable Power of Attorney;, Revocation of Prior General Powers of Attorney. This durable power of
attorney is not terminated by subsequent incapacity of the Principal except as provided in chapter 709, Florida
Statutes. V
I hereby revoke any previously executed general powers of attorney that may still be effective as of today. This
does not serve to revoke any previously executed powers of attorney given by me for speck purposes.
03. Powers and Authority of My Agent; Limitations on the Powers and Authority of My Agent.
A. Powers And Authority Granted To My Agent. My Agent or Attorney in Fact is granted the following
general powers and authority which are intended to be all-inclusive and not exclusive:
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JAN 3 0
5T, Lucie County, Permitdn9
01) To enter upon and take possession of any lands, buildings, tenements, or other structures, or any part or
parts thereof, that may belong to me, or the possession of which I may. be entitled, specifically including my homestead
property, all of which is herein, referred to as "my real estate."
02) To ask, collect and receive any rents, profits, issues, or income of any of my real estate or any part or
parts thereof.
03) To make, execute and deliver any deed, mortgage, lease, or any other document for conveying,
transferring, mortgaging, or granting any interest to all or any portion of my real estate whether with or without covenants
and warranties of title or condition of the improvements on the real estate.
Such right to convey, transfer, mortgage, to otherwise grant interests in my real estate shall specifically include
the right to join in any deed, mortgage, or other conveyance or encumbrance of homestead real estate owned by me or by
another for the purpose of satisfying the provisions of the State of Florida Homestead Laws as established by the Florida
Constitution, Florida Statutes, and any other laws or regulations requiring my signature to convey or encumber interests in
real property.
If I am married, my Agent may not mortgage or convey homestead property without joinder of my spouse or my
spouse's guardian. Joinder by my spouse may be accomplished by the exercise of authority in a power of attorney
executed by my spouse and either of us may appoint the other as Agent for the other.
04) To demand, sue for, collect,, recover and receive all goods, claims, debts, monies, interest and demands
whatsoever now due, or belonging to me (including the right to institute any action, suit or legal proceeding, for the
recovery of any land, buildings, tenements or other structures or any part or parts thereof, to the possession whereof I may
be entitled), and to make, execute and deliver receipts, releases or other discharges therefor, under seal or otherwise.
05) To make, execute, endorse, accept and deliver any and all bills of exchange, drafts, notes and trade
acceptances.
06) To pay all sums of money, at any time or times, that may hereafter be owing by me upon any bill of
exchange, check, draft, note or trade acceptance, made, executed, endorsed, executed and delivered by me, or for me, or in
my name, by my- said Attorney in Fact.
07) To deposit with any bank or bankers in my name, any monies which may come to my Attorney in Facts
hands in his capacity as Attorney in Fact.
08) To withdraw and use as my Attorney in Fact shall think fit in the payment of any debts, interest, taxes,
assessments, insurance, or expenses due and payable or to become due and payable on account of my real and personal
estate, or in or about any of the purposes herein mentioned, or otherwise for my use and benefit, any money to which I am
entitled which now is or shall be so deposited with any bank or bankers.
09) To enter any safe deposit box or other depository held in my name or jointly with any other person and to
remove or deposit any property, cash, documents, or other items therein.
10) To invest in my name in any stocks, shares, bonds, securities or other property, real or personal, as my
Attorney in Fact may think proper, and to receive and give receipts for any income or dividend arising from such
investments, and all and any such investments or other investments to vary or dispose of for my use and benefit as my
Attorney in Fact may think fit.
11) To sell and convey any and all shares of stock, bonds, membership units, or other securities now, or
hereafter belonging to me, that may be issued by any association, trust, limited liability company, or corporation, whether
private or public, to make, execute and deliver any assignment of securities, and to vote said shares of stock and
membership units.
12) To defend, settle, adjust, compound, submit to arbitration and compromise all actions, suits, accounts,
reckonings, claims and demands, whatsoever, that now are, or hereafter shall be, pending between me and any person,
firm or corporation in such manner and in all respects as my said Attorney in Fact shall think fit.
l3) To sell and convey, either at public or private sale, or exchange any part or parts of my real estate or
personal property for such consideration and upon such terms as my Attorney in Fact shall think fit, and to execute and
deliver good and sufficient deeds or other instruments for the conveyance or transfer of the same, with such covenants of
warranty or otherwise as my Attorney in Fact shall see fit, and to give good effectual receipts for all or any part of the
purchase price or other consideration.
14) To cant' on or to wind up any;,, business, and in connection therewith to use the premises in which the
same is or shall be carried on, with the same powers of dealing with stock, capital, and effects, and of entering into
business engagements, of increasing and diminishing capital, and generally of transacting the affairs of the said business
as I myself have or should have.
15) To engage, employ and dismiss any agents, clerks, servants or other persons in and about the performance
of these presents as my Attorney in Fact shall think fit.
16) To exercise any powers and duties vested in me, whether solely or jointly, with any other or others as
executor, administrator, or trustee or in any other fiduciary capacity, so far as such power or duty is capable of being
validly delegated.
17) To pay every month the sums required to meet my ordinary household expenses.
18) To prepare, sign, and file an Income Tax Return or Declaration of Estimated Tax elected to be filed under
the Internal Revenue Code for any taxable year during the period this Power of Attorney continues to be in effect. Also,
to represent me before any office of the Internal Revenue Service with respect to any and all Internal Revenue tax matters
and any and all years or periods. To receive confidential information and have full power to perform, on my behalf, the
following acts with respect to any matter as to which this Power of Attorney shall apply:
a) To receive, and to endorse and collect, checks in payment of any refund of Internal Revenue
Taxes, penalties or interest;
b) To execute waivers (including offers of waivers) or restrictions on assessment or collection of
deficiencies in tax and waivers of notice of disallowance of claim for credit or refund;
c) To execute consents extending the statutory period for assessment or collection of taxes; and
d) To delegate authority or to substitute another representative.
19) To enter, make, sign, execute and deliver, acknowledge and perform any contract, agreement, writing or
thing that may, in the opinion of my Attorney in Fact be necessary or proper to be entered into, made or signed, sealed,
executed, delivered, acknowledged, or performed.
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20) To transfer any assets of mine to a revocable living trust established by me for my lifetime benefit or the
lifetime benefit of my spouse and me, with the remaining trust assets passing to such beneficiaries as I may have named in
such trust, after my death.
21) To execute stock powers or similar documents on my behalf and to delegate to a transfer agent or similar
person the authority to register any stocks, bonds, membership interests, or other securities either into or out of my name
or my nominee's name.
22) To demand, obtain, and review. any documentation and information pertaining to any indebtedness owed
by me or by any entity owned by me and to negotiate and execute any agreement pertaining to any such debt including
debt modifications, debt reinstatements, debt reduction, .debt payment, debt settlements (including defense of legal actions
and transfers of assets in settlement of debt obligations). My Agent may hire and appoint third parties to do any or all of
the above.
23) To conduct banking transactions as provided in section 709.2208(1), Florida Statutes.
24) To conduct investment transactions as provided in section 709.2208(2), Florida Statutes.
25) To conduct any business related to any of my benefits from military service.
26) To conduct any business related to my governmental and non -governmental retirement benefits and plans
and my pensions.
B. Powers And Authority Granted To My Agent Which Requires My Separate Approval In
Accordance With Florida Statute Sec. 709.2202. The following powers next to which I have initialed
yes are granted to my Agent:
Yes 01) To create an inter vivos trust agreement on my behalf, naming me as the Grantor or Settlor, upon
such terms and with such trustee or trustees as my Attorney in Fact shall select my Attorney in Fact may
be named as the sole trustee), which trust shall provide:
a) that the trustees are granted comprehensive and complete powers of disposition or sale of
the property transferred to the trust, including my homestead property;
b) that the trustees shall be paid a reasonable fee for their services and, in the case of a
corporate trustee, that the fee may be charged according to its fee schedule as published from time to
time;
c) that all income and principal shall be paid to me or to my spouse and me, to some person
for my benefit or for the benefit of my spouse and me, or applied for my benefit or for the benefit of my
spouse and me in such amounts as I or my Agent shall request or as the trustee or trustees shall determine
in the trustees' discretion as is sufficient to provide suitable support for me and my spouse considering
available assets from the trust and other sources:
d) and that upon the death of me and, if applicable, my spouse, any remaining income and
principal shall be divided among my surviving issue, in equal shares, by right of representation, subject to
withholding of possession by the trustee, for the benefit of such issue, until such age or ages as my Agent
deems prudent, in my Agent's discretion, and providing for distribution to the surviving issue of a
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deceased beneficiary (or to my surviving issue, if none) in the event the initial beneficiary does not
survive until final distribution of his or her trust share.
Such trust may be revoked or amended by me or my Attorney in Fact at any time and from time
to time; provided, however, that any amendment by my Attorney in Fact must be such that by law or
under the provisions of this instrument such amendment could have been included in the original trust
agreement.
My Attorney in Fact shall have the power to deliver and convey any or all of my assets to the
trustee or trustees of any trust created by my Attorney in Fact pursuant to this specific power and, for the
purpose of funding any trust, to enter and remove any of my cash or property from any safe-deposit box
of mine (whether the box is registered in my name alone or jointly with one or more other persons) for
delivery to the trustee.
Yes 13 51C 02) To create and fund any income only trust (qualified income trust and/or "Miller" Trust), with all or
part of my income from any -source necessary to obtain Medicaid benefits for me, create trust accounts
with banks therefore, obtain, an employer identification number for such trust, and transfer all income of
mine from other bank accounts to such trust account. To execute and fund an irrevocable trust for the
benefit of any disabled child or grandchild of mine, either as an independently administered trust or as
part of a pooled trust administered by a not -for -profit organization, upon such terms and conditions as my
Attorney -in -Fact shall stipulate, should I need long term nursing home institutionalization and may
qualify for Medicaid benefits but for the funds to be used for said trust. To comply with Medicaid rules
and laws and create and fund a trust for the benefit of my spouse should I become institutionalized in a
nursing home so as to qualify me for Medicaid benefits.
Yes 03) With respect to a trust created by or on behalf of me, to amend, modify, revoke, or terminate the
trust, but only if the trust instrument explicitly provides for amendment, modification, revocation, or
termination by my agent.
Yes 04) Make a gift of any of my property, outright to, or for the benefit of, a person, including by the
exercise of a presently exercisable general power of appointment held by me in accordance with the
following applicable initialed or signed provision
(If you have initialed yes to allow your Agent to be able to make gifts on your behalf, then choose which
one of the following is to control how gifts are to be made by your Agent):
a) No Limits On Gifts. There shall not be any limitations on the authority of my Agent to
make gifts; OR
b) Gifts to Family Members Only; Gifts Limited In Amounts. In my Attorney in Facts
sole judgment and without liability, my Attorney in Fact and agent is specifically directed and given the power to make
such gifts from my assets as are necessary to carry out, on my behalf, any plan or pattern of family or charitable gifts
which had theretofore apparently been established or clearly contemplated by me and which, in the opinion of my legal
counsel or legal counsel for my Attorney in Fact, a duly appointed guardian for me would be permitted to make and
would deem advisable to make from the assets of a guardianship estate, including the making of additions to any then
existing Trust or Trusts.
I specifically authorize the making of annual gifts to any of my family members, including my Attorney in Fact, if
he or she is a family member, in an amount per donee which does not exceed the annual dollar limits of the federal gift tax
exclusion under 26 U.S.C. s. 2503(b), as amended, without regard to whether the federal gift tax exclusion applies to the
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gift, or if I am married and if my spouse agrees to consent to a split gift pursuant to 26 U.S.C. s. 2513, as amended, then
the amount of the gift to each donee shall not exceed twice the annual federal gift tax exclusion limit. Subject to the
above maximum limit, the gifts shall be in such amounts as my Attorney in Fact deems advisable for my family's best
interests.
For the purposes of this paragraph "family members" shall be limited to my spouse, if any, and my issue, whether
naturally born or legally adopted, and nothing in this paragraph shall require my Attorney in Fact to make equal gifts to
family members. My Attorney in Fact shall have the sole judgment and discretion to determine whether or not any certain
family member should receive a gift from me and in what amount. OR
c) Gifts Not Limited To Family Members; Gifts Limited In Amounts. As provided
by Florida Statute 709.2202 (3), each gift made by my Agent shall be in an amount per donee which does not exceed the
annual dollar limits of the federal gift tax exclusion under 26 U.S.C. s. 2503(b), as amended, without regard to whether
the federal gift tax exclusion applies to the gift, or if I am married and if my spouse agrees to consent to a split gift
pursuant to 26 U.S.C. s. 2513, as amended, then the amount of the gift to each donee shall not exceed twice the annual
federal gift tax exclusion limit.
Also, if I am married, then my Agent may give my consent, pursuant to 26 U.S.C. s. 2513, as amended, to the
splitting of a gift made by my spouse in an amount per donee which does not exceed the aggregate annual gift tax
exclusions for both me and my spouse.
Yes 05) To create or change rights of survivorship.
Yes 06) To create or change a beneficiary designation.
Yes 07) To waive the principal's right to be a beneficiary of a joint and survivor annuity, including a
survivor benefit under a retirement plan.
Yes 08) To disclaim property and powers of appointment.
Yes 09) To demand, obtain, review, and release to others medical records or other documents protected by
the patient -physician privilege, attorney -client privilege, or any similar privilege, including all
records subject to, and protected by, the Health Insurance Portability and Accountability Act of
1996, as amended ("HIPAA"). I designate my Attorney in Fact as my personal representative
under HIPAA.
(Do not initial this provision if you have executed a separate health care surrogate form.)
As confirmation of my selections, I have elected to not give to my Agent the powers listed -in the above numbered
paragraphs:
All of the paragraphs; or
4 S It 01 and 03 through 09; or
O1 02 03 04
05 06 07 08 09
C. Pursuant to Florida Statutes Section 709.2201 (3), notwithstanding any other provision of this document,
my Agent may not:
01) Perform duties under a contract that requires the exercise of personal services of the principal.
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02) Make any affidavit as to the personal knowledge of the principal.
03) Vote in any public election on behalf of the principal.
04) Execute or revoke any'will or codicil for the principal.
05) Exercise powers and authority granted to the principal as trustee or as court -appointed fiduciary.
04. Third Party Reliance. For the purpose of inducing any individual, organization, or entity, all of whom will be
referred to in this Section as a "person," to act in accordance with the instructions of my Agent as authorized in
this document, I hereby represent, warrant and agree that:
A. Reliance on Agent's Authority and Representations. No person who relies in good faith upon the
authority of my Agent under this document shall incur any liability to me, my estate, my heirs, successors
or assigns. In addition, no person who relies in good faith upon any representation my Agent may make
as to the following shall incur any liability to me, my estate, my heirs, successors or assigns for permitting
my Agent to exercise any such authority:
01) the fact that my Agent's powers are in effect,
02) the scope of my Agent's authority granted under this document,
03) my competency at the time this document is executed,
04) the fact that this document has not been revoked, or
05) the fact that my, Agent continues to serve as my Agent.
B. No Liability for Unknown Revocation or Amendment. If this document is revoked or amended for
any reason, I, my estate, my heirs, successors and assigns will hold any person harmless from any loss
suffered or liability incurred as a result of such person acting in good faith upon the instructions of my
Agent prior to the receipt of such person of actual notice of such revocation or amendment.
C. Agent May Act Without My Joinder. The powers conferred on my Agent by this document may be
exercised by my Agent without my joinder, and my Agent's signature or act under the authority granted in
this document may be accepted by persons as fully authorized by me and with the same force and effect
as if I were personally present, competent, and acting on my own behalf. Consequently, all acts lawfully
done by my Agent hereunder are done with my consent and shall have the same validity and effect as if I
were personally present and personally exercised the powers myself, and shall inure to the benefit of and
bind me, my estate, my heirs, successors, assigns and personal representatives.
D. Resort to Courts. I hereby authorize my Agent to seek on my behalf and at my expense:
01) A declaratory judgment from any court of competent jurisdiction interpreting the validity of this
document or any of the acts authorized by this document, but such declaratory judgment shall not
be necessary in order for my Agent to perform any act authorized by this document; or
02) A mandatory injunction requiring compliance with my Agent's instructions by any person
obligated to comply with instructions given by my Agent; or
03) Actual and punitive damages against any person obligated to comply with instructions given by
my Agent who negligently or willfully fails or refuses to follow such instructions.
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05. Duration of Power; Disability of Principal. The Power of Attorney expressed herein shall continue indefinitely
at the pleasure of the Principal.
This Durable Power of Attorney shall not be affected by physical disability or mental incompetence of the
Principal which renders the Principal incapable of managing Principal's own estate or affairs. The authority
conferred shall be exercisable notwithstanding physical disability or mental incompetence. All acts done by the
Attorney in Fact pursuant to the power during any period of disability or mental incompetence shall have the
same effect and inure to the benefit of and bind the Principal or the heirs, devisees, legatees, and personal
representatives of the Principal to the same extent as if the Principal were mentally competent and not disabled.
06. Miscellaneous Provisions. The following additional provisions shall apply to this document:
A:. Reimbursement of Costs. My Agent shall be entitled to reimbursement for all reasonable costs and
expenses actually incurred nand paid by my Agent on my behalf under any provision of this document, but
my Agent shall not be entitled to compensation for services rendered hereunder.
B. Execute Documents and Incur Costs In Implementing the Above Powers. My Agent shall be entitled
to sign, execute, deliver and acknowledge any contract or other document that may be necessary,
desirable, convenient or proper in order to exercise any of the powers described in this document and to
incur reasonable costs in'the exercise of any such powers. In addition, my Agent shall render bills for all
costs incurred in the exercise of the powers granted in this document to any other persons, attorneys -in -
fact, Agents or trustees holding funds of mine for my benefit, in order to seek payment of such expenses.
Any such persons are liereby directed to pay such expenses to the extent they are empowered to do so.
C. Governing Law. This document shall be governed by the laws of the State of Florida in all respects,
including its validity, construction, interpretation, and termination. I intend for this Durable Power of
Attorney to be honored in any jurisdiction where it may be presented and for any such jurisdiction to refer
to Florida law to interpret and determine the validity of this document and any of the powers granted
under this document.
D. Revocation and Amendments. I retain the right to revoke or amend this document. Amendments to this
document shall be made in writing by me personally and they shall be attached to the original of this
document.
E. Resignation of Agent. Any Agent appointed hereunder may resign by the execution of a written
resignation delivered to me or, if I am mentally incapacitated, by delivery to my legal guardian or
conservator, and absent such person then to any person with whom I am residing or who has the care and
custody of me, to any co -agent or, in the case of successively appointed Agents, by delivery to the next
Agent in order of succession.
In addition, the incapacity of any Agent appointed hereunder shall be deemed a resignation by such
individual as agent. For purposes of this paragraph, a person's incapacity shall be deemed to exist when
the person's incapacity has been declared by a court of competent jurisdiction, or when a conservator for
such person has been appointed; or upon presentation of a certificate executed by two (2) physicians
licensed to practice in the state of such person's residence which states the physicians' opinion that the
person is incapable of caring for himself or herself and is physically or mentally incapable of managing
his or her personal or financial affairs. The effective date of such incapacity shall be the date of the
decree adjudicating the incapacity, the date of the decree appointing the conservator, or the date of the
physicians' certificate, as the case may be.
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F. Photocopies. My Agent is authorized to make photocopies of this document as frequently and in such
quantity as my Agent shall deem appropriate. All photocopies shall have the same force and effect as any
original. I specifically direct my Agent to have a photocopy of this document placed in my medical
records if such a copy does not ah-eady constitute a part of my medical records.
G. Severability. If any part of any provision of this document shall be invalid or unenforceable under
applicable law, such part shall be ineffective to the extent of such invalidity only, without in any way
affecting the remaining parts of such provision or the remaining provisions of this document.
H. Exculpation. My Agent and my Agent's estate, heirs, successors and assigns are hereby released and
forever discharged by me, my estate, my heirs, successors and assigns from all liability and from all
claims or demands of all kinds arising out of the acts or decisions made by my Agent in good faith and
under this power of attorney; provided that this shall not apply if my Agent has acted with willful
misconduct or gross negligence or if my Agent has acted dishonestly, with improper motive, or with
reckless indifference to the purposes of this power of attorney or to my best interest.
I. Applicable In All Jurisdictions. This instrument is executed by me in the State of Florida, but it is my
intention that this Durable Power of Attorney shall be exercisable in any other state or jurisdiction where I
may have property or other interests which require management or administration.
I Notice: A notice, including, but not limited to,
01) a notice of revocation,
02) notice of partial or complete termination by adjudication of incapacity or by the occurrence of an
event referenced herein,
03) notice of death'of the principal,
04) notice of suspension by initiation of proceedings to determine incapacity or to appoint a guardian,
or
05) any other notice,
is not effective until written notice is served upon the Agent or any third persons relying upon this durable
power of attorney.
Notice must be in writing and must be accomplished in a manner reasonably suitable under the
circumstances and likely to result in receipt of the notice or document. Service of notice or for sending a
document includes first-class mail, personal delivery, delivery to the person's known place of residence or
place of business, or a properly directed facsimile or other electronic message.
Notice to a financial institution must contain the name, address, and the last four digits of my social
security number and be directed to an officer or a manager of the financial institution within the State of
Florida.
Notice is effective when given, except that notice upon a financial institution, brokerage company, or title
insurance company is not effective until 5 days, excluding Saturdays, Sunday, and legal holidays, after it
is received.
K. My Spouse. Where I have referred to my Spouse in this document, such wording shall be applicable
only if I am married at the time of the use of this document by my Agent.
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NOTE: BY SIGNING BELOW, I INDICATE THAT I UNDERSTAND THE CONTENTS OF THIS DOCUMENT
AND THE EFFECT OF THIS GRANT OF POWERS TO MY AGENT.
IN WITNESS WHEREOF, I sign my name to this Durable Power of Attorney and place my initials on the
bottom of each page thereof on SIGNINGDATE. In doing so, I do hereby confirm that I execute this document under
oath or affirmation that what is stated in this document is true and I acknowledge that I have freely executed this
document as my act.
BEATRICE S. KUPIEC, Principal
WITNESS STATEMENT:
Each of the witnesses signing below declares that the Principal signed and acknowledged this Durable Power of
Attorney in the presence of the witnesses and that the Principal appears to be of sound mind and under no duress, fraud, or
undue influence. Neither witness is the person appointed as Attorney in Fact or Agent by this document, nor is either
witness the Principal's health care provider, or an employee of the Principal's health care provider.
Each witness further declares that he or she is not the spouse of the Principal nor related to the Principal by blood,
marriage, or adoption, and to the best of each witness's knowledge, neither witness is now a creditor of the Principal nor
entitled to any part of the Principal's estate under a Will now existing or by operation of law.
Witness #1• Signature: ; Date:
Print Name:Telephone: (7M 210-5518
Address: c% W tlfa er G. Woods, P.A.'
2081 SE Ocean Blvd., Suite 2-B
Stuart, Florida 3 996 6
Witness #2: Signature: KL��c%��� Date: �O
Print Name: r 6, r.J1Z ds Telephone: (772) 210-5518
Address: c/o Walter G. Woods, P.A.
2081 SE Ocean Blvd., Suite 2-B
Stuart, Florida 34996
STATE OF FLORIDA
COUNTY OF MARTIN
The foregoing completed instrument,was sworn to, subscribed, and acknowledged before me this � day of
2016, by BEATRICE S. KUPIEC (the Principal), who personally appeared before me and who was in my presence at a time the
signature was notarized. As proof of identity of the Principal, I have relied upon the following checked item:
my inspection of a driver's license issued by the Florida Department of Highway Safety and Motor Vehicles, issued
to the Principal, which was either current or issued within the 5 years immediately preceding the date of this
acknowledgment, or
my personal knowledge of the identity of the Principal.
The Principal is not known by me to have been adjudicated mentally incapacitated (unless the person has been restored to
mental health as a matter of record) and I have no reason to believe otherwise. The Principal is not related to me by blood or
marriage, and the Principal is specifically not my spouse, son, daughter, mother or father. I have no financial interest in, and I am not
a party to, the underlying transaction. The Principal speaks and understands the English language. The Principal did take an oath.
Signature of Notary Public
(Notary Stamp or Seal) My Commission Expires:
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