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Power of Attorney, DC 6:12 PSC, Rev. 08/12 §30-4041
Nebraska Power of Attorney
DESIGNATION OF AGENT
I (your name) name the following person as my agent (individual
with power of attorney):
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: ________________________
If my successor agent is unable or unwilling to act for me, I name as my second successor
Name of Second Successor Agent: __________________
RELEASE OF INFORMATION
I agree to, authorize, and allow full release of information, by any governmental agency,
business, creditor, or third party who may have information pertaining to my assets or income, to
my agent named on this form.
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 Nebraska Uniform Power of Attorney Act):
(CHECK 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 check "All Preceding Subjects" instead
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