N.C. Gen. Stat. § 32C-3-301
As a nonexclusive method to grant a power of attorney, a document substantially in the following form may be used to create a statutory form power of attorney that has the meaning and effect prescribed by this Chapter:
"NORTH CAROLINA
STATUTORY SHORT FORM POWER OF ATTORNEY
NOTICE: THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD AND SWEEPING. THEY ARE DEFINED IN CHAPTER 32C OF THE NORTH CAROLINA GENERAL STATUTES, WHICH EXPRESSLY PERMITS THE USE OF ANY OTHER OR DIFFERENT FORM OF POWER OF ATTORNEY DESIRED BY THE PARTIES CONCERNED.
IMPORTANT INFORMATION
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 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 North Carolina Uniform Power of Attorney Act.
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 entitled to reasonable compensation unless you state otherwise in the Additional Provisions and Exclusions.
This form provides for designation of one agent, successor agent, and second successor agent. If you wish to name more than one agent, successor agent, and second successor agent, you may name a coagent, successor coagent, or second successor coagent in the Additional Provisions and Exclusions. Coagents, successor coagents, or second successor coagents are not required to act together unless you include that requirement in the Additional Provisions and Exclusions.
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.
If you have questions about the 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 the following person as my agent:
Name of Agent:
________________________________ (Name of Principal).
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:
If my successor agent is unable or unwilling to act for me, I name as my second successor agent:
Name of Second Successor Agent:
INITIAL below if you want to give an agent the power to name a successor agent.
(_____) I give to my acting agent the full power to appoint another to act as my agent, and full power to revoke such appointment, if no agent named by me above is willing or able to act.
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 North Carolina Uniform Power of Attorney Act, Chapter 32C of the General Statutes:
(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 MAY 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.)
(_____) Make a gift, subject to the limitations provided in G.S. 32C-2-217
(_____) Create or change rights of survivorship
(_____) Create or change a beneficiary designation
(_____) Authorize another person to exercise the authority granted under this power of attorney
(_____) Waive my right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan
(_____) Exercise fiduciary powers that I have authority to delegate
(_____) Disclaim or refuse an interest in property, including a power of appointment
(_____) Access the content of electronic communications.
EXERCISE OF SPECIFIC AUTHORITY IN FAVOR OF AGENT
(OPTIONAL)
(_____) UNLESS INITIALED, an agent MAY NOT exercise any of the grants of specific authority initialed above in favor of the agent or an individual to whom the agent owes a legal obligation of support.
ADDITIONAL PROVISIONS AND EXCLUSIONS
(OPTIONAL)
(_____) __________________________________________________________________
___________________________________________________________________
EFFECTIVE DATE
This power of attorney is effective immediately.
NOMINATION OF GUARDIAN
(OPTIONAL)
INITIAL below ONLY if you WANT your acting agent to be your Guardian.
(_____) If it becomes necessary for a court to appoint a guardian of my estate or a general guardian, I nominate my agent acting under this power of attorney to be the guardian to serve without bond or other security.
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.
MEANING AND EFFECT
The meaning and effect of this power of attorney shall for all purposes be determined by the law of the State of North Carolina.
SIGNATURE AND ACKNOWLEDGMENT
_________________________________ ___________________________
Your Signature Date
_________________________________
Your Name Printed
State of __________________________, County of ________________________.
I certify that the following person personally appeared before me this day, acknowledging to me that he or she signed the foregoing document: __________________________________.
Date: _____________________________ ____________________________
Signature of Notary Public
(Official Seal)
___________________________, Notary Public
Printed or typed name
My commission expires:______________________
"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 you and the principal. This relationship imposes upon you legal duties that continue until you resign or your authority is terminated or the power of attorney is terminated or revoked. You must:
Unless the Additional Provisions and Exclusions in this power of attorney state otherwise, you must also:
Termination of Agent's Authority
You must stop acting on behalf of the principal if you learn of any event that terminated or revoked 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:
Liability of Agent
The meaning of the authority granted to you is defined in the North Carolina Uniform Power of Attorney Act. If you violate the North Carolina Uniform Power of Attorney Act 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."
N.C. Gen. Stat. § 32C-3-301