New York State Bar Association
New York Statutory Short Form Power of Attorney, Eff. 6/13/21
3
( ) (H) claims and litigation;
( ) (I) personal and family maintenance: If you grant your agent this authority, it will allow the agent to
make gifts that you customarily have made to individuals, including the agent, and charitable
organizations. The total amount of all such gifts in any one calendar year cannot exceed five
thousand dollars;
( ) (J) benefits from governmental programs or civil or military service;
( ) (K) financial matters related to health care; records, reports, and statements;
( ) (L) retirement benefit transactions;
( ) (M) tax matters;
( ) (N) all other matters;
( ) (O) full and unqualified authority to my agent(s) to delegate any or all of the foregoing powers to
any person or persons whom my agent(s) select;
( ) (P) EACH of the matters identified by the following letters ______________________________.
You need not initial the other lines if you initial line (P).
(g) CERTAIN GIFT TRANSACTIONS: (OPTIONAL)
In order to authorize your agent to make gifts in excess of an annual total of $5,000 for all gifts
described in (I) of the grant of authority section of this document (under personal and family maintenance),
and/or to make changes to interest in your property, you must expressly grant that authorization in the
Modifications section below. If you wish to authorize your agent to make gifts to himself or herself, you
must expressly grant such authorization in the Modifications section below. Granting such authority to your
agent gives your agent the authority to take actions which could significantly reduce your property and/or
change how your property is distributed at your death. Your choice to grant such authority should be
discussed with a lawyer.
( ) I grant my agent authority to make gifts in accordance with the terms and conditions of the
Modifications that supplement this Statutory Power of Attorney.
(h) MODIFICATIONS: (OPTIONAL)
In this section, you may make additional provisions, including, but not limited to, language to limit
or supplement authority granted to your agent, language to grant your agent the specific authority to make
gifts to himself of herself, and /or language to grant your agent the specific authority to make other gift
transactions and/or changes to interests in your property. Your agent is entitled to be reimbursed from your
assets for reasonable expenses incurred on your behalf. In this section, you may make additional provisions
if you ALSO wish your agent(s) to be compensated from your assets for services rendered on your behalf,
and you may define “reasonable compensation.”
(i) DESIGNATION OF MONITOR(S): (OPTIONAL)
If you wish to appoint monitor(s), initial and fill in the section below:
( ) I wish to designate ____________________, whose address(es) is (are) ______________________,
as monitor(s). Upon the request of the monitor(s), my agent(s) must provide the monitor(s) with a copy of
the power of attorney and a record of all transactions done or made on my behalf. Third parties holding
records of such transactions shall provide the records to the monitor(s) upon request.