2015 Connecticut General Statutes
Title 1 - Provisions of General Application
Chapter 15c - Connecticut Uniform Power of Attorney Act
Section 1-352 - (Note: This section is effective July 1, 2016.) Power of attorney form.

(a) The use of the following form in the creation of a power of attorney is authorized, and, when used, it shall be construed in accordance with the provisions of sections 1-350 to 1-353b, inclusive:

“Notice: The powers granted by this document are broad and sweeping. They are defined in Connecticut Uniform Power of Attorney Act, which expressly permits the use of any other or different form of power of attorney desired by the parties concerned. The grantor of any power of attorney or the agent may make application to a court of probate for an accounting as provided in subsection (b) of section 45a-175 of the general statutes. This power of attorney does not authorize the agent to make health care decisions for you.

Know All Persons by These Presents, which are intended to constitute a GENERAL POWER OF ATTORNEY pursuant to Connecticut Uniform Power of Attorney Act:

That I .... (insert name and address of the principal) do hereby appoint .... (insert name and address of the agent, or each agent, if more than one is designated) my agent(s) TO ACT .....

If more than one agent is designated and the principal wishes each agent alone to be able to exercise the power conferred, insert in this blank the word ‘severally’. Failure to make any insertion or the insertion of the word ‘jointly’ shall require the agents to act jointly.

First: In my name, place and stead in any way which I myself could do, if I were personally present, with respect to the following matters as each of them is defined in the Connecticut Uniform Power of Attorney Act to the extent that I am permitted by law to act through an agent:

(Strike out and initial in the opposite box any one or more of the subdivisions as to which the principal does NOT desire to give the agent authority. Such elimination of any one or more of subdivisions (A) to (M), inclusive, shall automatically constitute an elimination also of subdivision (N).)

To strike out any subdivision the principal must draw a line through the text of that subdivision AND write his initials in the box opposite.

(A)	real estate transactions (real property);	( )
(B)	chattel and goods transactions (tangible personal property);	( )
(C)	bond, share and commodity transactions (stocks and bonds);	( )
(D)	banking transactions (banks and other financial institutions);	( )
(E)	business operating transactions (operation of entity or business);	( )
(F)	insurance transactions (insurance and annuities);	( )
(G)	estate transactions (estates, trusts, and other beneficial interests);	( )
(H)	claims and litigation;	( )
(I)	personal relationships and affairs (personal and family maintenance);	( )
(J)	benefits from military service (benefits from governmental programs or civil or military service);	( )
(K)	records, reports and statements;	( )
(L)	retirement plans;	( )
(M)	taxes;	( )
(N)	all other matters;	( )
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(Special provisions and limitations may be included in the statutory form power of attorney only if they conform to the requirements of the Connecticut Uniform Power of Attorney Act.)

(Strike out below and initial in the opposite box any one or more of the subdivisions as to which the principal does NOT desire to give the agent authority. To strike out any subdivision the principal must draw a line through the text of that subdivision AND write his initials in the box opposite.)

(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.)

	YOU SHOULD SEEK LEGAL ADVICE BEFORE INCLUDING THE FOLLOWING POWERS:
(O)	Create, amend, revoke or terminate an inter vivos trust, provided in the case of a trust established for a disabled person pursuant to 42 USC 1396p (d)(4)(A) or 42 USC 1396p (d)(4)(C), the creation of such trust by an agent shall be only as permitted by federal law	( )
(P)	Make a gift, subject to the limitations of the Connecticut Uniform Power of Attorney Act and any special instructions in this power of attorney. Unless otherwise provided in the special instructions, gifts per recipient may not exceed the annual dollar limits of the federal gift tax exclusion under Internal Revenue Code Section 2503(b), or if the principal’s spouse agrees to consent to a split gift pursuant to Internal Revenue Code Section 2513, in an amount per recipient not to exceed twice the annual federal gift tax exclusion limit. In addition, an agent must determine that gifts are consistent with the principal’s objectives if actually known by the agent and, if unknown, as the agent determines is consistent with the principal’s best interest based on all relevant factors	( )
(Q)	Create or change rights of survivorship	( )
(R)	Create or change a beneficiary designation	( )
(S)	Authorize another person to exercise the authority granted under this power of attorney	( )
(T)	Waive the principal’s right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan	( )
(U)	Exercise fiduciary powers that the principal has authority to delegate	( )
(V)	Disclaim or refuse an interest in property, including a power of appointment	( )

Second: With full and unqualified authority to delegate any or all of the foregoing powers to any person or persons whom my agent(s) shall select;

Third: Hereby ratifying and confirming all that said agent(s) or substitute(s) do or cause to be done.

Fourth:

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.

Fifth:

DESIGNATION OF SUCCESSOR AGENT(S) (OPTIONAL)

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: _________________________

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:___________________

Sixth:

EFFECTIVE DATE

This power of attorney is effective immediately unless I have stated otherwise in the special instructions.

In Witness Whereof I have hereunto signed my name and affixed my seal this .... day of ...., 20...

.... (Signature of Principal) (Seal)

(ACKNOWLEDGMENT)

The execution of this statutory form power of attorney shall be duly acknowledged by the principal in the manner prescribed for the acknowledgment of a conveyance of real property.

No provision of this chapter shall be construed to bar the use of any other or different form of power of attorney desired by the parties concerned.

Every statutory form power of attorney shall contain, in boldface type or a reasonable equivalent thereof, the “Notice” at the beginning of this section.

(b) A power of attorney is a “statutory form power of attorney”, as this phrase is used in sections 1-350 to 1-353b, inclusive, when it is in writing, has been duly acknowledged by the principal and contains the exact wording of clause First set forth in subsection (a) of this section, except that any one or more of subdivisions (A) to (V) may be stricken out and initialed by the principal, in which case the subdivisions so stricken out and initialed and also subdivision (N) shall be deemed eliminated. A statutory form power of attorney may contain modifications or additions of the types described in sections 1-350 to 1-353b, inclusive.

(c) If more than one agent is designated by the principal, such agents, in the exercise of the powers conferred, shall act jointly unless the principal specifically provides in such statutory short form power of attorney that they are to act severally.

(d) (1) The principal may indicate that a power of attorney duly acknowledged in accordance with this section shall take effect upon the occurrence of a specified contingency, including a date certain or the occurrence of an event, provided that an agent designated by the principal executes a written affidavit that such contingency has occurred.

(2) The principal may indicate the circumstance or date certain upon which the power of attorney shall cease to be effective.

(e) The following optional informational form may be used as part of the Statutory Form or as part of a separate document from the Statutory Form.

IMPORTANT INFORMATION FOR AGENT

Agent’s Duties

When you accept the authority granted under this power of attorney, a special legal relationship is created between you and the principal. This relationship continues 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;

(2) Act in good faith;

(3) Do nothing beyond the authority granted in this power of attorney; and

(4) 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) by (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

(6) 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 through divorce or annulment, 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 Connecticut Uniform Power of Attorney Act, sections 1-350 to 1-353b, inclusive. If you violate the Connecticut Uniform Power of Attorney Act, sections 1-350 to 1-353b, inclusive, or act outside the authority granted, you may be liable for any damages caused by your violation.

If there is anything about this document or your duties that you do not understand, you should seek legal advice.

(P.A. 15-240, S. 41.)

History: P.A. 15-240 effective July 1, 2016.