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I, ________________, appoint my ______________, _________________, as my

attorney-in-fact (herein called my attorney). My attorney shall have all of the powers to
act for me and on my behalf that are given under this power of attorney. If my
designated attorney resigns, such attorney shall sign a resignation of such power and
deliver it to me. I grant to my attorney full power to take all actions for me and for my
benefit that my attorney considers wise, including but not limited to the following:

(a) to endorse my name upon checks payable to me, and to make deposits in an
account in a bank or savings and loan institution in my name or in my name
and the name of another, and to open such accounts in my name; to sign my
name to checks or withdrawal slips for the purpose of withdrawing such
funds for my benefit; to endorse my name upon commercial paper of any
kind; to enter any safe deposit box to which I have access, to make deposits
in it and to remove contents from it;

(b) to manage my property, and to invest my funds in such deposits, securities,

or other property (including real property) as my attorney considers wise
without regard to any statute or rule restricting investments by fiduciaries;
to purchase and sell United States securities (including securities
redeemable at par in payment of federal estate taxes) and other securities
with respect to which the Treasury Department acts as the transfer agency;
to take any action with reference to my securities that my attorney
considers wise; to provide or cancel insurance on my property or for my
benefit; to borrow money on my behalf; to pledge, mortgage, sell, convey,
or otherwise dispose of my interest in any property (real or personal) on any
terms my attorney considers wise, to any person except my attorney; to sign
on my behalf any appropriate instruments, including promissory notes,
mortgages, deeds, and bills of sale; to lease property, for any term, as lessee
or lessor; to continue the operation of any business in which I have an
interest for such period of time and in such manner as my attorney
considers wise; to enter into general or limited partnership, limited liability
company, and stockholder agreements, syndicates, joint enterprises,
corporate reorganizations, mergers, consolidations, and any other
incorporated or unincorporated business ventures; to execute certificates
relating to the admission or increased contribution of partners or members;

(c) to institute and maintain any action or proceeding my attorney considers

wise; to defend any action or proceeding which is instituted against me; to
compromise any claim, litigation or other controversy, whether, asserted by
or against me, upon such terms as my attorney considers wise, and to give
such releases as my attorney considers wise;

(d) to sign and file for me any tax return or other document to be filed with any
federal, state, county, municipal, or foreign agency; to represent me in any
proceeding, conference or litigation which may arise in connection with any
such tax returns signed by me or by my attorney; to take any action in
connection with tax matters as my attorney considers wise, including
execution of consents, waivers, extensions, agreements, Forms 2848
(Power of Attorney), offers in compromise and settlements;

(e) to employ and compensate employees, lawyers, agents, experts,

accountants, and investment advisors; to delegate authority to them and to
rely upon information or advice furnished by them:

(f) to acknowledge any distribution or notice to me from any fiduciary or other

person, and to give receipt and approval of it for filing with a court or
otherwise; to accept, renounce, release, waive, and disclaim, in whole or in
part, any property to which I may be entitled;

(g) to make contributions in any calendar year to any one or more

organizations to which I have made contributions during the three calendar
years previous to the date of the first contribution made pursuant to this
power, such contribution to any organization in any calendar year to be not
more than the amount of contributions I have made to it in one of such
previous three years; and to pay any pledge I have made to any

(h) to transfer to or withdraw from the Trustee, any part or all of my assets, as
my attorney deems appropriate, of any trust of which the assets are, or are
to be, under the terms of the governing instrument held primarily or solely
for my benefit during my lifetime;

(i) to exercise any right to elect benefits, terminate, surrender, change, assign
rights or ownership, borrow against, or receive cash value, with respect to
any life insurance or annuity policy, retirement, profit sharing, or other
benefit program, subject however to ERISA and Internal Revenue
restrictions with respect to retirement plan benefits; provided, however, no

such right with respect to any insurance policy shall be exercisable if my
attorney is the insured thereunder;

(j) to make decisions respecting my care and custody, including but not limited
to placing me in and removing me from any hospital, other health care
facility, or other place of residence, and to execute any agreement with
respect thereto; provided, however, if I designate an attorney-in-fact under
a power of attorney for health care, the authority granted herein shall be
subordinate to the authority granted therein;

(k) to make gifts (authorized but not directed), outright or in trust, to or for the
benefit of any one or more of (1) my spouse and either (2) my descendants
(including the spouse of a descendant as a descendant of mine for this
purpose) so long as the gifts to all such persons at a generational level are
the same for that year; or (3) my descendants (including the spouse of a
descendant as a descendant of mine for this purpose) so long as the
aggregate gifts to each child, his or her spouse, and his or her descendants
do not exceed in the aggregate the gifts made during that year to another
child of mine, his or her spouse, and his or her descendants. Gifts under
(1), (2), and (3) shall be subject to the following limitations: (A) the
choice as to whether to make the gifts subject to (2) or (3) of this paragraph
shall be in the sole discretion of my attorney; (B) my attorney shall not be
prohibited from receiving a gift hereunder, if he or she is otherwise a
permissible recipient under the provisions of this paragraph, and (C) in no
event shall any gift in any calendar year to any permitted individual,
including my attorney, exceed the then available annual exclusion from gift
taxes in any year or if permitted, twice this amount if my spouse agrees to
be treated as having made one-half of such gifts;

(l) to (whether or not I am competent) communicate with, receive disclosure

of, and execute waivers of restrictions on disclosure of, any and all
individually identifiable health information relevant to me, whether past,
present or future, without restriction or limitation, from any health care
provider or other entity required to maintain my medical records
confidentially by the Health Insurance Portability and Accountability Act of
1996 (HIPAA), as currently codified at 42 USC 1320d, with regulations
implementing its effect at 45 CFR 160-164, as they now exist and as they
may be amended (hereinafter, the “HIPAA Rules”). The authority given to
my Attorney hereunder shall supersede any prior agreement that I may have
made with my health care providers to restrict access to or disclosure of my
individually identifiable health information. The authority of my Attorney
has no expiration date, and shall expire as to any health care provider only
if I revoke the authority and actual notice of the revocation has been given

to that health care provider. This Power of Attorney is specifically intended
to comply with the requirements of the HIPAA Rules and shall be so

(m) without limiting any of the express powers granted hereinabove, I hereby
give and grant to my said attorney full power and authority to do and
perform all and every act and thing whatsoever necessary to be done in the
premises, as fully to all intents and purposes as I might or could do if
personally present, with full power of substitution and revocation, hereby
ratifying and confirming all that my said attorney may do pursuant to this

This power of attorney shall not be affected by my disability or the lapse of time.

I reserve the right to revoke this power of attorney. If my attorney requests any
institution or person to rely on this power of attorney, such institution or person may rely
on it until such institution or person has actual knowledge of its revocation; and if I die
and my attorney takes any action under this power of attorney involving such institution
or person before such institution or person has actual knowledge of my death, then such
action shall be binding upon my estate as if I were living at the time of such action.

In the event that it is determined that proceedings for the appointment of a

guardian for my person, estate, or both should be commenced, then I hereby nominate for
consideration by the court, my attorney acting hereunder as guardian for my person,
estate, or both, and further grant to my attorney the authority to nominate a successor
guardian for my person, estate, or both for consideration by a court. I direct that no bond
be required for any person nominated as guardian or successor guardian pursuant to this
power of attorney.

I have signed this power of attorney in the state of Ohio, but it is my intention that
it be exercisable in any other state or jurisdiction.

Signed on ________________________, 2010.


) SS :

BEFORE ME, a notary public in and for the State of Ohio, personally appeared
the above named ____________________, who acknowledged that she signed the
foregoing instrument as her voluntary act.

IN WITNESS WHEREOF, I have hereunto set my hand and seal on

_________________, 2010.

Notary Public