633B.301  Power of attorney — form.
  A document substantially in the following form may be used to create a statutory power of attorney that has the meaning and effect prescribed by this chapter:
IOWA STATUTORY POWER OF ATTORNEY FORM
   1.  POWER OF ATTORNEY
   This power of attorney authorizes another person (your agent) to make decisions concerning your property for you (the principal). Your agent will be able to make decisions and act with respect to your property (including but not limited to your money) whether or not you are able to act for yourself. The meaning of authority over subjects listed on this form is explained in the Iowa Uniform Power of Attorney Act, Iowa Code chapter 633B.
   This power of attorney does not authorize the agent to make health care decisions for you.
   You should select someone you trust to serve as your agent. Unless you specify otherwise, generally the agent’s authority will continue until you die or revoke the power of attorney or the agent resigns or is unable to act for you.
   Your agent is not entitled to compensation unless you state otherwise in the optional Special Instructions.
   This form provides for designation of one agent. If you wish to name more than one agent, you may name a coagent in the optional Special Instructions. Coagents must act by majority rule unless you provide otherwise in the optional Special Instructions.
   If your agent is unable or unwilling to act for you, your power of attorney will end unless you have named a successor agent. You may also name a second successor agent.
   This power of attorney becomes effective immediately upon signature and acknowledgment unless you state otherwise in the optional Special Instructions.
   If you have questions about this power of attorney or the authority you are granting to your agent, you should seek legal advice before signing this form.
DESIGNATION OF AGENT
   I _________________________ (name of principal) name the following person as my agent:
   Name of Agent ____________________________________________
   Agent’s Address __________________________________________
   Agent’s Telephone Number _________________________________
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 __________________________________
   Successor Agent’s Address ________________________________
   Successor Agent’s Telephone Number _______________________
   If my successor agent is unable or unwilling to act for me, I name as my second successor agent:
   Name of Second Successor Agent ___________________________
   Second Successor Agent’s Address _________________________
   Second Successor Agent’s Telephone Number ________________
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 Iowa Uniform Power of Attorney Act, Iowa Code chapter 633B:
   (Initial 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 initial “All Preceding Subjects” instead of initialing each subject.)
   ___ Real Property
   ___ Tangible Personal Property
   ___ Stocks and Bonds
   ___ Commodities and Options
   ___ Banks and Other Financial Institutions
   ___ Operation of Entity or Business
   ___ Insurance and Annuities
   ___ Estates, Trusts, and Other Beneficial Interests
   ___ Claims and Litigation
   ___ Personal and Family Maintenance
   ___ Benefits from Governmental Programs or Civil or Military Service
   ___ Retirement Plans
   ___ Taxes
   ___ All Preceding Subjects
GRANT OF SPECIFIC AUTHORITY (OPTIONAL)
   My agent shall not do any of the following specific acts for me unless I have initialed the specific authority listed below:
   (Caution: Granting any of the following will give your agent the authority to take actions that could significantly reduce your property or change how your property is distributed at your death. Initial only the specific authority you WANT to give your agent.)
   ___ Amend, revoke, or terminate a revocable inter vivos trust, if authorized by the trust.
   ___ Agree to the amendment or termination of any other inter vivos trust.
   ___ Make a gift to an individual who is not an agent, subject to the limitations of the Iowa Uniform Power of Attorney Act, Iowa Code section 633B.217, and any special instructions in this power of attorney.
   Make gifts, either direct or indirect, to my agent acting under this power of attorney as follows:
   ___ Any such gift must be approved in writing by ________________; or
   ___ No third-party approval is needed.
   ___ Authorize another person to exercise the authority granted under this power of attorney.
   ___ Waive the principal’s right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan.
   ___ Exercise fiduciary powers that the principal has authority to delegate.
   ___ Disclaim or refuse an interest in property, including a power of appointment.
LIMITATION ON AGENT’S AUTHORITY
   An agent that is not my ancestor, spouse, or descendant shall not use my property to benefit the agent or a person to whom the agent owes an obligation of support unless I have included that authority in the optional Special Instructions.
SPECIAL INSTRUCTIONS (OPTIONAL)
   You may give special instructions on the following lines:
   ___________________________________________________________
   ___________________________________________________________
   ___________________________________________________________
   ___________________________________________________________
   ___________________________________________________________
   ___________________________________________________________
   ___________________________________________________________
   ___________________________________________________________
   ___________________________________________________________
   ___________________________________________________________
   ___________________________________________________________
   _________________________ shall have the authority to request an accounting of any agent.
EFFECTIVE DATE
   This power of attorney is effective immediately upon signature and acknowledgment unless I have stated otherwise in the optional Special Instructions.
NOMINATION OF CONSERVATOR AND GUARDIAN (OPTIONAL)
   If it becomes necessary for a court to appoint a conservator of my estate or guardian of my person, I nominate the following person(s) for appointment:
   Name of Nominee for Conservator of My Estate _____________
   Nominee’s Address ________________________________________
   Nominee’s Telephone Number _______________________________
   Name of Nominee for Guardian of My Person ________________
   Nominee’s Address ________________________________________
   Nominee’s Telephone Number _______________________________
RELIANCE ON THIS POWER OF ATTORNEY
   Any person, including my agent, may rely upon the validity of this power of attorney or a copy of it unless that person knows it has terminated or is invalid.
SIGNATURE AND ACKNOWLEDGMENT
_____________________________                    _________________________
Your Signature                          Date
_____________________________
Your Name Printed
_____________________________
_____________________________
Your Address
_____________________________
Your Telephone Number
State of ____________________
County of ___________________
This document was acknowledged before me on _______________ (date), by __________________________ (name of principal)
_____________________________                      (Seal, if any)
Signature of Notary
My commission expires ________________
This document prepared by
___________________________________________________________
___________________________________________________________
   2.  IMPORTANT INFORMATION FOR AGENT
AGENT’S DUTIES
   When you accept the authority granted under this power of attorney, a special legal relationship is created between the principal and you. This relationship imposes upon you legal duties that continue until you resign or the power of attorney is terminated or revoked. You must do all of the following:
   Do what you know the principal reasonably expects you to do with the principal’s property or, if you do not know the principal’s expectations, act in the principal’s best interest.
   Act in good faith.
   Do nothing beyond the authority granted in this power of attorney.
   Disclose your identity as an agent whenever you act for the principal by writing or printing the name of the principal and signing your own name as agent in the following manner:
_______________________ (principal’s name) by 
_______________________ (your signature) as Agent
   Unless the Special Instructions in this power of attorney state otherwise, you must also do all of the following:
   Act loyally for the principal’s benefit.
   Avoid conflicts that would impair your ability to act in the principal’s best interest.
   Act with care, competence, and diligence.
   Keep a record of all receipts, disbursements, and transactions made on behalf of the principal.
   Cooperate with any person that has authority to make health care decisions for the principal to do what you know the principal reasonably expects or, if you do not know the principal’s expectations, to act in the principal’s best interest.
   Attempt to preserve the principal’s estate plan if you know the plan and preserving the plan is consistent with the principal’s best interest.
TERMINATION OF AGENT’S AUTHORITY
   You must stop acting on behalf of the principal if you learn of any event that terminates this power of attorney or your authority under this power of attorney. Events that terminate a power of attorney or your authority to act under a power of attorney include any of the following:
   Death of the principal.
   The principal’s revocation of the power of attorney or your authority.
   The occurrence of a termination event stated in the power of attorney.
   The purpose of the power of attorney is fully accomplished.
   If you are married to the principal, a legal action is filed with a court to end your marriage, or for your legal separation, unless the Special Instructions in this power of attorney state that such an action will not terminate your authority.
LIABILITY OF AGENT
   The meaning of the authority granted to you is defined in the Iowa Uniform Power of Attorney Act, Iowa Code chapter 633B. If you violate the Iowa Uniform Power of Attorney Act, Iowa Code chapter 633B, or act outside the authority granted, you may be liable for any damages caused by your violation.
   If there is anything about this document or your duties that you do not understand, you should seek legal advice.

2014 Acts, ch 1078, §43