I,__________,of________,hereby appoint_____,of___________,as my attorney in fact to act in my capacity to do every act that I may legally do through an attorney in fact. This power shall be in full force and effect on the date below written and shall remain in full force and effect until_______________or unless specifically extended or rescinded earlier by either party.

　　Dated____,____,__
　　STATE OF_________
　　COUNTY OF___,____