Temporary Power of Attorney Authorization Form

Date:

I, (Full Name of Principal):

Address:

Phone Number:

hereby appoint (Full Name of Attorney-in-Fact):

Address:

Phone Number:

as my Temporary Power of Attorney, to act on my behalf for the following matters and within the dates specified below:

Start Date:

End Date:

Special Instructions or Limitations (if any):

Principal's Signature:

Date:

Attorney-in-Fact's Signature:

Date:

Witness (if required): Signature:

Date: