SPECIFIC POWER OF ATTORNEY
 This limited and specific power of attorney is given on:     [DATE]          
	by:      [YOUR NAME - the donor]    , 
	of:         [YOUR FULL ADDRESS]             .
I appoint:     [FULL NAME OF ATTORNEY - person you are giving power to] , 
	of:     [ATTORNEY’S FULL ADDRESS]             to be my attorney.
Said attorney-in-fact shall have full power and authority to undertake and perform only the following acts on my behalf:
●	[DESCRIBE THE SPECIFIC ACT OR ACTS YOU WISH THE ATTORNEY TO PERFORM FOR YOU] 
●	
The authority herein shall include such incidental acts as are reasonably required to carry out and perform the specific authorities granted herein. 
This power of attorney is subject to the following conditions or restrictions:
●	The authority granted under this power of attorney ends if I become mentally incompetent.
●	[LIST ANY OTHER RESTRICTIONS YOU MAY WANT ON THE POWER – OR PRINT: No other restrictions. ]
The rights, powers, and authority herein granted shall be in full force and effect:
	[PRINT: Until: (the date you want the power to expire)]
[OR PRINT: Indefinitely ]

Date:                                     
Signature of Donor:                                                              
Printed Name of Donor:                                                       

Witnessed:
Date:                                     

Notary Public in and for Ontario
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