North Dakota Financial Power of Attorney Form

The North Dakota Financial Power of Attorney is a form that can be used for enabling another person to act on your behalf in any monetary decisions.

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Checklist for Completing	 
NDPERS’ Durable Power of Attorney	
 
 	
This checklist is provided to help you make certain that you have completed all information required on 
NDPERS’ Durable Power of Attorney prior to submitting it to NDPERS.  (It is not necessary to return this 
checklist to NDPERS.) 
 	
 1.  I am of sound mind and acting of my own free will. 
 
  2.  The individual I have selected as my attorney-in-fact to make retirement system-related 
decisions for me is at least 18 years old. 
 
  3.  I realize that in the event I become incompetent, or upon my request, my attorney-in-fact 
has the power and authority to transact all matters relating to the Public Employees 
Retirement System or the Highway Patrol System. 
 
  4.  I have spoken with the individual I have selected as my attorney-in-fact and this individual 
has agreed to participate. 
 
  5.  I have signed and dated the durable power of attorney. 
 
  6.  I have had the durable power of attorney notarized. 
 
  7.  I have given a notarized copy of the completed durable power of attorney to those people, 
including my attorney-in-fact and family members, who may need it in case an emergency 
arises which requires a decision.

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DURABLE POWER OF ATTORNEY	 	
1. Creation of Durable Power of Attorney for Retirement System-Related Business 
By this document I intend to create a durable power of attorney by appointing the person designated 
below to make retirement system-related decisions on my behalf and as allowed by the North Dakota 
Century Code.  This power is expressly limited to decisions relating to my benefits under the Public 
Employee Retirement System and the Highway Patrol Retirement System. 
2. Designation of Attorney-in-fact 
I,                   , of               ,     	
(Name of Member or Beneficiary)             (Street Address) 
 
 	
 City of            , County of       , 
 
 
  State of                    do hereby appoint: 
 
 
                   of                      , 
       	
(Name of Attorney-in-Fact)                (Street Address) 
 
 	
City of                 , County of            , 
 
 
  State of                   , as my attorney-in-fact. 
 
3. General Statement of Authority Granted 
 
I hereby grant to my attorney-in-fact full power and authority to transact all matters relating to the 
North Dakota Public Employees Retirement System (NDPERS) and the Highway Patrol Retirement 
System (HPRS).  This authority includes, but is not limited to, filing applications, making benefit 
elections, designating beneficiaries, changing an address, setting up direct deposit, and endorsing 
warrants. 
I further grant my attorney-in-fact full power and authority to do and perform every act necessary and 
proper to be done in the exercise of any of the foregoing powers as fully as I might do or could do if

- 6 -  personally present.  I hereby ratify and confirm all that my attorney lawfully does or causes to be done 
by virtue of this power of attorney. 
The authority granted by this Durable Power of Attorney is limited to retirement system matters, and does not 
extend to any of my real or other personal property.	 
4. Duration 
My attorney-in-fact is instructed to notify NDPERS in writing of my disability, incapacity, or my death 
immediately upon its occurrence.  My subsequent disability, incapacity, or lapse of time shall not 
affect this power of attorney. 
This power of attorney is effective for the period                 to 
                    .  (Insert specific dates or the words “upon the event of 	
disability or incapacity	” and “indefinite	”). 
 
Warning to Person Executing This Document	
 
This is an important legal document.  It creates a durable power of attorney.  Before executing this document, 
you should know these important facts: 
 
X These powers will exist for an indefinite period of time unless you limit their duration in this 
document.  These powers will continue notwithstanding your subsequent disability or 
incapacity. 
 
X You have the right to revoke or terminate this power of attorney. 
 
X If there is anything in this document that you do not understand, you should ask a lawyer to 
explain it to you.

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Date and Signature of Principal	 	
 
Executed this                day of               ,            , at         , 
       (Date)  (Month)       (Year)    (City) 
 
                 . 
 	
(State) 
 	
    Signature 
     Typed or Printed Name 
     Social Security Number 	
  
 	
Acknowledgement of Notary Public	 	
State of     ) 
       S.S. 
County of     ) 
 
On                ,          ,                  personally appeared before  
  (Month/Day)  (Year)   (Name) 
 
me on the basis of satisfactory evidence to be the person whose name is subscribed to the within power of 
 
attorney and acknowledged that      executed the same. 
                 (he/she) 
 
        
 
 (seal) 
      Residing at   
 
      My Commission expires: