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Notice: The powers granted by this document are broad and sweeping. They are defined in Connecticut Statutory Short Form Power of Attorney Act, sections I-42 to I-56, inclusive, of the general statutes, which expressly permits the use of any other different form of power of attorney desired by the parties concerned,

KNOW ALL MEN BY THESE PRESENTS, Which are intended to constitute a GENERAL POWER OF ATTORNEY pursuant to Connecticut Statutory Short Form Power of Attorney Act:

That I: _____________________ do hereby appoint: _____________________________ my attorney(s)-in-fact TO ACT:

FIRST, In my name, place and stead in any way which I myself could do, if I were personally present, with respect to health care decisions as defined in the Connecticut Statutory Short Form Power of Attorney Act to the extent that I am permitted by law to act through an agent:

SECOND, With full and unqualified authority to delegate any or all of the foregoing powers to any person or persons whom my attorney(s)-in-fact shall select.

THIRD, Hereby ratifying and confirming all that said attorney(s) or substitute(s) do or cause to be done.

FOURTH, This Power of Attorney shall not be affected by my subsequent disability or incompetence of the principal herein named.

FIFTH, I hereby agree that any third party receiving a copy or facsimile of this executed instrument may act in reliance thereon and that revocation or termination of this power of attorney shall be ineffective as to such third party unless and until actual notice or knowledge thereof shall have been received by such third party, and I, for myself and my heirs, assigns and legal representatives, hereby agree to indemnify and hold harmless any such third party from and against any and all claims that may arise against such third party by reason of reliance on such copy of this instrument.

If more than one agent is designated and the principal wishes each agent alone to be able to exercise the power conferred, insert in this blank the word ‘severally’. Failure to make any insertion or the insertion of the word ‘jointly’ shall require the agent to act jointly.

SIXTH, Ihereby declare that, with respect to the powers conferred by this executed instrument, any and all such powers which may have been conferred in a previously executed instrument or instruments are hereby revoked.

In Witness Whereof, I have hereunto signed my name and affixed my seal this _____ day of ______________ 200__.

Signed, sealed and delivered in the presence of:

_____________________________ Witness

_____________________________ Signature of Principal

_____________________________ Witness

STATE OF CONNECTICUT)

COUNTY OF ) ss.

The foregoing POWER OF ATTORNEY was acknowledged before me this day of _________, 200__, by __________________________.(Principal)

_________________________________________

Notary Public Commissioner of the Superior Court