SPECIAL POWER OF ATTORNEY STATE OF ... - Connecticut

1 STATE OF CONNECTICUTDEPARTMENT OF MOTOR VEHICLES60 STATE STREET, WETHERSFIELD, CT 06161 SPECIAL POWER OF ATTORNEYA-83 REV. 6-2008 INSTRUCTIONS: The form below may be used as a SPECIAL POWER of ATTORNEY to authorize, according to Connecticut law, another persondesignated by you to make, to complete and to sign on your behalf an application for a motor vehicle registration and certificate of title, orother written document, form or application that is required to be filed with the Commissioner of Motor Vehicles in connection with any othertransactions involving a motor vehicle registration or note the following carefully:This form must be completed in its entirety. The form requires your signature, the signature of two witnesses, and the signature of anofficer authorized to take acknowledgments (a Notary Public, Justice of the Peace, or Commissioner of the Superior Court).

2 The SPECIAL POWER of ATTORNEY does not authorize your agent to perform transactions related to your motor vehicle operator's license oridentification card, or other transactions with the Commissioner that are unrelated to a motor vehicle registration or SPECIAL POWER of ATTORNEY , bearing original signatures must be shown and will be returned to grantor of any SPECIAL POWER of ATTORNEY or the ATTORNEY -in-fact may make application to any Court of Probate for an accounting, asprovided in subsection (b) of section 45a-175 of the Connecticut General ALL PERSONS BY THESE PRESENTS, which are intended to constitute a SPECIAL POWER of ATTORNEY , that I,(Print your full name above), do hereby appoint(Print full name of your agent above)

3 , as my ATTORNEY -in-factto act in my name, place and stead in any way which I myself could do, as if I were personally present, to the full extentpermitted by law to act as an agent, to make, to complete, and to execute any application or other written document or formthat is required to be filed with the Commissioner of Motor Vehicles of the STATE of Connecticut , pursuant to the authority thatis granted to the said Commissioner by any provision of the General Statutes of Connecticut or the regulations of ConnecticutState Agencies, in connection with the registration of any motor vehicle or the certificate of title to any motor vehicle . ThisSpecial POWER of ATTORNEY is granted and is valid only for the express purposes stated herein, and may not be used for anytransaction involving any other person or party who is not named WITNESS WHEREOF, I have hereunto signed my name below on thisday of, :( )(Sign your full name as above)Attested and subscribed in the presence of the Principaland subsequent to the Principal subscribing same:(Signature of Witness)(Signature of Witness) STATE OF Connecticut ) )COUNTY OF )SS.

4 Personally appeared, signer and sealer of the foregoing POWER of ATTORNEY , whoacknowledged the same as his or her free act and deed, before me, thisday of, Public/Justice of PeaceCommissioner of the Superior CourtMy commission expires:_____Seal of the Notary Public or Justice of Peace(Full name of Principal)