The SJCERA Special Power of Attorney form is a crucial document that authorizes someone else to make decisions on your behalf, specifically relating to your retirement plan with the San Joaquin County Employees' Retirement Association. It's a powerful tool for ensuring your interests are managed according to your wishes, especially in circumstances where you might not be able to do so yourself. For those looking to secure their retirement decisions, filling out this form is an essential step.
The importance of preparing for the future cannot be understated, particularly when it comes to financial affairs and retirement benefits. One tool individuals have at their disposal for addressing these areas is the Sjcera Special Power of Attorney form. Designed with the specific needs of beneficiaries in mind, this legal document allows for the delegation of financial decision-making authority to a trusted individual, often in circumstances where the original party is unable to manage their affairs directly. This special power of attorney form is tailored to the administration of retirement and related benefits, ensuring that participants can appoint someone to handle their interests without the wide-ranging powers of a general power of attorney. It provides peace of mind, knowing that decisions regarding one's retirement benefits are in capable hands, while also setting parameters that protect the principal from potential misuse of authority. The form is an essential part of retirement planning, providing a secure pathway for managing and protecting one's financial future efficiently.
SPECIAL POWER OF ATTORNEY
SECTION 1
When completing this form, please be sure to print the requested information.
For the purpose of this form, a principal is defined as a person who empowers another to act as a representative on that person's behalf.
Creation of Special Durable Power of Attorney for Retirement-Related Business
Name of Principal (First Name, Middle Initial, Last Name)
Social Security Number or SJCERA ID
Address
County
(
)
City
State
Zip
Daytime Phone
By this document I intend to create a durable power of attorney by appointing the person named below to make retirement-related decisions for me as allowed by the California Probate Code. This power is expressly limited to decisions relating to my benefits under the San Joaquin County Employees' Retirement Association, hereinafter
SJCERA.
SECTION 2
You have the option of designating more than one Attorney-in-Fact.
Designation of Attorney-in-Fact
If you appoint more than one attorney-in-fact, and you want each attorney-in-fact to be able to act alone, check the appropriate box. If you do not check a box, or if you check “jointly,” then all of your attorneys-in-fact must act or sign together. Granting joint authority to two or more attorneys-in-fact is exercisable only by their unanimous action. If you choose to have your attorneys-in-fact act jointly, and one is unavailable because of absence, illness, or other temporary incapacity, the other attorney(s)-in-fact may exercise their authority under the power of attorney.
Name of Attorney-in-Fact
(First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
Social Security Number
I have designated more than one Attorney-in-Fact. They are to act (mark one box only): Jointly
Separately
Alternately, in the numerical order specified above. If you mark "Alternately," you must number the Attorneys- in-Fact in the order in which they are to act.
SJCERA Special POA
Page 1 of 5
Put your name and
Social Security
Number or SJCERA
ID at the top of every Name of PrincipalSocial Security Number or SJCERA ID page
SECTION 3 General Statement of Authority Granted
I hereby grant my Attorney-in-Fact full authority to transact all matters on my behalf relating to SJCERA, including, but not limited to, filing applications, making benefit elections, designating beneficiaries and endorsing warrants. I further give my Attorney-in-Fact full authority to perform every required act to be done to exercise any of the foregoing powers as fully as I might or could do if personally present, hereby ratifying and confirming all that my Attorney-in-Fact shall lawfully do or cause to be done. I understand that this authority is granted to the Attorney-in-Fact designated by me even if that person is related to be my blood, marriage, or legal domestic partnership. By signing this Special Power of Attorney form, I intend that:
My Attorney-in-Fact ( is;
is not) authorized to select any payment option available under the
•retirement plan, even though it may reduce the monthly allowance that would otherwise be paid to me during my lifetime.
•My Attorney-in-Fact (☐ is; ☐ is not) authorized to designate or change my beneficiary.
•My Attorney-in-Fact (☐ is; ☐ is not) authorized to designate himself or herself as my beneficiary.
•I give the following instructions that limit or extend the powers granted to my Attorney-in-Fact:
SECTION 4
Please be careful in choosing when you want your power of attorney to commence or terminate.
Duration of Power of Attorney
Please check one box to indicate your choice.
Unless I indicate otherwise, this power of attorney is effective immediately and will continue until it is revoked. My Attorney-in-Fact is hereby instructed to notify SJCERA in writing of my disability, incapacity, or death immediately upon its occurrence.
This special durable power of attorney is to commence immediately and to remain in effect for my lifetime or until I specifically cancel it.
This special limited power of attorney is to commence on ____________________ and
terminate on ____________________________ .
Date (mm/dd/yyyy)
Date (mm/dd/yyyy) or Event
This special contingent power of attorney is to commence only upon a determination that I am incapacitated and/or unable to handle my own affairs. The determination of whether I am incapacitated and/or unable to handle my own affairs shall be made by
____________________________________________________________ .
Name or Title of Person to Make the Determination
This special general power of attorney is to terminate in its entirely if I become incapacitated.
Page 2 of 5
SECTION 5
Agent is the Attorney-in-Fact.
Notice to Person Executing Durable Power of Attorney
The authority granted by the SJCERA Special Power of Attorney form is limited to matters related to SJCERA. The person designated as your Attorney-in-Fact does not have any authority over your other real or personal property. If you wish that your Attorney-in-Fact have authority over your real and/or personal property, it is recommended that you seek legal counsel.
You may notice that the language contained in the following (Warning) statement refers to more extensive authority than granted by the SJCERA Special Power of Attorney. This (Warning) statement is required by California Probate Code Section 4128 to be included in all pre-printed power of attorney forms even though the SJCERA Special Power of Attorney does not authorize your Attorney-in-Fact to do many of the things mentioned in the following (Warning) statement. Also, if you are concerned with the (Warning) statement or the extent of the authority being granted by the SJCERA Special Power of Attorney form, we again urge you to consult with an attorney.
(Warning): Notice to Person Executive Durable Power of Attorney
A durable power of attorney is an important legal document. By signing the durable power of attorney, you are authorizing another person to act for you, the principal. Before you sign this durable power of attorney, you should know these important facts:
•Your agent has no duty to act unless you and your agent agree otherwise in writing.
•This document gives your agent the powers to manage, dispose of, sell, and convey your real and personal property, and to use your property as security if your agent borrows money on your behalf. This document does not give your agent the power to accept or receive any of your property, in trust or otherwise, as a gift, unless you specifically authorize the agent to accept or receive a gift.
•Your agent will have the right to receive reasonable payment for services provided under this durable power of attorney unless you provide otherwise in this power of attorney.
•The powers you give your agent will continue to exist for your entire lifetime, unless you state that the durable power of attorney will last for a shorter period of time or unless you otherwise terminate the durable power of attorney. The powers you give your agent in this durable power of attorney will continue to exist even if you can no longer make your own decisions regarding the management of your property.
•You can amend or change this durable power of attorney only by executing a new durable power of attorney or by executing an amendment through the same formalities as an original. You have the right to revoke or terminate this durable power of attorney at any time, so long as you are competent.
•This durable power of attorney must be dated and must be acknowledged before a notary public or signed by two witnesses. (Please choose one or the other, but not both!) If it is signed by two witnesses, they must witness either (1) the signing of the power of attorney or (2) the principal’s signing or acknowledgment of his or her signature. A durable power of attorney that may affect real property should be acknowledged before a notary public so that it may be easily recorded.
•You should read this durable power of attorney very carefully. When effective, this durable power of attorney will give your agent the right to deal with property that you now have or might acquire in the future. The durable power of attorney is important to you. If you do not understand the durable power of attorney, or any provision of it, then you should obtain the assistance of an attorney or other qualified person.
Page 3 of 5
SECTION 6
To be reviewed and signed by the Attorney in-Fact
Notice to Person Accepting the Appointment of Attorney-in-Fact
By acting or agreeing to act as the agent (attorney-in-fact) under this power of attorney, you assume the fiduciary and other legal responsibilities of an agent. These responsibilities include:
•The legal duty to act solely in the interest of the principal and to avoid conflicts of interest
•The legal duty to keep the principal’s property separate and distinct from any other property owned or controlled by you.
You may not transfer the principal’s property to yourself without full and adequate consideration or accept a gift of the principal’s property unless this power of attorney specifically authorizes you to transfer property to yourself or accept a gift of the principal’s property. If you transfer the principal’s property to yourself without specific authorization in the power of attorney, you may be prosecuted for fraud and/or embezzlement. If the principal is 65 years of age or older at the time that the property is transferred to you without authority, you may also be prosecuted for elder abuse under Penal Code Section 368. In addition to criminal prosecution, you may also be sued in civil court.
Print Name of Agent
Signature of Agent
SECTION 7
To be completed and signed by the Principal.
Principal's Acknowledgement and Execution
I am of sound mind and either understand my elections or talked with an attorney. I am executing this legal document under my own free will.
Print Name of Principal
Signature of Principal
Date Executed (mm/dd/yyyy)
Page 4 of 5
SECTION 8
To be completed and signed by two witnesses who are not named as Attorneys- in-Fact.
Witness Information
I have witnessed the Principal's signature or the Principal's acknowledgment of the signature designating power of attorney. I attest to the Principal's knowledge that I am of sound mind. I am an adult at least 18 years old and not the Attorney-in-Fact. My signature certifies that the Principal is known to me, is the same person who signed and dated this affidavit and that the Principal is of sound mind.
Signature of Witness 1
Print Name of Witness 1
Witness 1 Address
SECTION 9
To be completed by a notary public.
This section does not need to be completed if you have completed Section 8. SJCERA images these documents. Please be advised embossed seals may not appear when this document is imaged. An inked stamp is preferred.
Notary Public Acknowledgement
Notary
StateCounty
On _______________________ before me ________________________________________________,
Date (mm/dd/yyyy)Printed Name of Notary Public
personally appeared ________________________________________, who proved to me on the basis of
Printed Name of Principal
satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her authorized capacity, and that by his/her signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument. I certify under Penalty of Perjury under the laws of the State of California that the foregoing paragraph is true and correct.
Witness my hand and official seal.
Signature of Notary Public
Notary Seal
Printed Name of Notary Public
MAIL TO:
SJCERA • 6 S. El Dorado Street, Suite 400 • Stockton, California • 95202-2804
Page 5 of 5
05/2020
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