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CANADA)I, _____________________________, of
)the _______ of ________________, in the
PROVINCE OF MANITOBA)Province of Manitoba,
make oath and say that:
1.I was personally present and did see the within Limited Power of Attorney and
Acknowledgement duly signed, sealed and executed by the donor of the power,
_____________________, at the ________ of _________________, in the Province of
Manitoba, on the _________ day of ________________, 20__ and at the time of
execution the donor was, in my opinion, of sound mind, memory and understanding.
2.I know the donor and he/she is, in my belief, eighteen (18) years of age or more.
3.I am a subscribing witness to the Limited Power of Attorney and Acknowledgement.
4.The Limited Power of Attorney and Acknowledgement was executed by the donor in my
presence (or the donor acknowledged his or her signature in my presence), whereupon I
did, in the presence of the donor, subscribe the Limited Power of Attorney and
Acknowledgement as a witness.
SWORN BEFORE me at the _______ of)
_________________, in Manitoba, this)
_______ day of ______________, 20__.)
A Commissioner for Oaths in and)
for the Province of Manitoba)
My Commission Expires:
NOTE TO SOLICITOR:
In circumstances where transfer or mortgage documents must be substantially amended or re-executed by
the solicitor under the Limited Power of Attorney, the Land Titles Office may require that, in addition to
filing the Limited Power of Attorney, the solicitor furnish evidence to the effect that:
1.the documents executed or amended by the grantee under the Limited Power of Attorney relate to
the lands described in the Limited Power of Attorney; and
2.the documents executed or amended by the grantee under the Limited Power of Attorney relate to
the transaction described in the Limited Power of Attorney.
Solicitors should consult with the Land Titles Office to determine its specific requirements in any
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