WISCONSIN POWER OF ATTORNEY

NOTICE:  THIS IS AN IMPORTANT DOCUMENT.  BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS.   BY SIGNING THIS DOCUMENT, YOU ARE NOT GIVING UP ANY POWERS OR RIGHTS TO CONTROL YOUR FINANCES AND PROPERTY YOURSELF.  IN ADDITION TO YOUR OWN POWERS AND RIGHTS, YOU ARE GIVING ANOTHER PERSON, YOUR “AGENT,” POWERS TO HANDLE YOUR FINANCES AND PROPERTY.  THIS DOCUMENT DOES NOT AUTHORIZE ANYONE TO MAKE MEDICAL OR OTHER HEALTH CARE DECISIONS FOR YOU.  IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN THIS FORM TO YOU BEFORE YOU SIGN IT.

IF YOU WISH TO CHANGE YOUR WISCONSIN POWER OF ATTORNEY, YOU MUST COMPLETE A NEW DOCUMENT AND REVOKE THIS ONE.  YOU MAY REVOKE THIS DOCUMENT AT ANY TIME BY DESTROYING IT, BY DIRECTING ANOTHER PERSON TO DESTROY IT IN YOUR PRESENCE OR BY SIGNING A WRITTEN AND DATED STATEMENT EXPRESSING YOUR INTENT TO REVOKE THIS DOCUMENT.  IF YOU REVOKE THIS DOCUMENT, YOU SHOULD NOTIFY YOUR AGENT AND ANY OTHER PERSON TO WHOM YOU HAVE GIVEN A COPY OF THE FORM.  YOU ALSO SHOULD NOTIFY ALL PARTIES HAVING CUSTODY OF YOUR ASSETS.  THESE PARTIES HAVE NO RESPONSIBILITY TO YOU UNLESS YOU ACTUALLY NOTIFY THEM OF THE REVOCATION.  IF YOUR AGENT IS YOUR SPOUSE AND YOUR MARRIAGE IS ANNULLED, OR YOU ARE DIVORCED AFTER SIGNING THIS DOCUMENT, THIS DOCUMENT IS INVALID.

YOU SHOULD SIGN THIS FORM ONLY IF THE AGENT YOU NAME IS RELIABLE, TRUSTWORTHY AND COMPETENT TO MANAGE YOUR AFFAIRS.

I,                                                                                                              [name of student] permanently residing at:                         
                                                                                                                                                                                             [address],

appoint    	

[name   of  person  appointed]  who  is  my

                                                                     [relationship to student] as my agent to act for me in any lawful way with respect to the powers initialed below.

TO GRANT ONE OR MORE OF THE FOLLOWING POWERS, INITIAL THE LINE IN FRONT OF EACH POWER YOU ARE GRANTING.  TO WITHHOLD A POWER, DO NOT INITIAL THE LINE IN FRONT OF IT.  YOU MAY, BUT NEED NOT, CROSS OUT EACH POWER WITHHELD.

POWERS GRANTED (Initial those granted):

 	 1.   PAYMENTS OF BILLS:   My agent may make payments that are necessary or appropriate in connection with the administration of my affairs (including in connection with my educational expenses).

           2.  BANKING:  My agent may conduct business with financial institutions, including endorsing all checks and drafts made payable to my order (including checks and drafts in connection with financial aid for my education) and collecting the proceeds; signing in my name checks or orders on all accounts in my name or for my benefit; withdrawing funds from accounts in my name; opening accounts in my name; and entering into and removing articles from my safe deposit box.

 	3.  INSURANCE:  My agent may obtain insurance of all types, as considered necessary or appropriate, settle and adjust insurance claims and borrow from insurers and third parties using insurance policies as collateral.

           4.  ACCOUNTS:  My agent may ask for, collect and receive money, dividends, interest, legacies and property due or that may become due and owing to me and give receipt for those payments.

This Wisconsin Power of Attorney becomes effective when I sign it BUT WILL CEASE TO BE EFFECTIVE IF I BECOME DISABLED OR INCAPACITATED.  Unless terminated or revoked earlier by me, this Wisconsin Power of Attorney will expire one year from the date of my signature below.

I agree that any third party who receives a copy of this document may act under it.  Revocation of this Wisconsin Power of Attorney is not effective as to a third party until the third party learns of the revocation.  I agree to reimburse the third party for any loss resulting from claims that arise against the third party because of reliance on this Wisconsin Power of Attorney.

Signed this             day of                                             , 20        .

Printed Name of Student	Signature of Student

Social Security Number

WITNESS SIGNATURES:

By signing as a witness, I am acknowledging the signature of the principal who signed in my presence and the presence of the other witness, and the fact that he or she has stated that this power of attorney reflects his or her wishes and is being executed voluntarily.  I believe him or her to be of sound mind and capable of creating this power of attorney.  I am not related to him or her by blood, marriage or adoption, and, to the best of my knowledge, I am not entitled to any portion of his or her estate under his or her will.

WITNESS		WITNESS		
Dated:	 		Dated:	 		
Signature:	 		Signature:	 		
Print Name:	 		Print Name:	 		
Address:	 		Address:	 		

NOTARIZATION1:

State of  		)
) County of  		)
)
Country of  		)

This document was acknowledged before me on this  	 day of  	_, 20_ 	 by  	
 	.

Signature of Notarial Officer

Title

My commission expires:   	

(Seal, if any)

ACCEPTANCE BY AGENT:

BY ACCEPTING OR ACTING UNDER THE APPOINTMENT, THE AGENT SIGNING BELOW ASSUMES THE FIDUCIARY AND OTHER LEGAL RESPONSIBILITIES AND LIABILITIES OF AN AGENT.

Printed Name of Agent	Signature

Date                                                                                             Relationship to Student

*   *   *   *   *

This document was drafted by the University of Wisconsin—Milwaukee Office of Legal Affairs.

1 In order for a notarization taking place outside the United States to be valid, it must be performed under the jurisdiction of the foreign nation by any of the following persons: (1) a notary public or notary; (2) a judge, clerk, or deputy clerk of a court of record; or (3) any other person authorized by the law of that jurisdiction to perform notarial acts.  The official stamp or seal of the person performing the notarization should be affixed on this page.

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