Limited Power of Attorney Authorization

This Limited Power of Attorney is made on (date), by ("Principal"), residing at .

I hereby appoint

("Agent"), residing at

as my true and lawful attorney-in-fact to act in my name and stead in connection with the following acts and powers:

Effective Date: Expiration Date:

Special Instructions or Limitations (if any):

Principal's Signature: Date:

Witness Signature: Date: