Pennsylvania Limited (Special) Power of Attorney Form

The Pennsylvania limited (special) power of attorney form is a legal document that allows a Principal to delegate certain responsibilities to another individual who shall be referred to as the “Agent”. The Agent will only receive authorization from the Principal if the circumstance(s) established within the document are met (e.x. if the Principal is incarcerated, becomes ill, etc.). Upon receiving authorization, the Agent shall execute the Principal’s commands in good faith and within the scope of the authority defined within the form. The Principal must sign the form in front of two (2) witnesses who are of legal age and the form must be acknowledged by a Notary Public or other authorized individual.

How to Write

Step 1 – Notice – The Principal should read the following:

  • Notice
  • Incapacitation
  • Revocation
  • Witness and Notary
  • AND
  • Terms and Conditions
  • Third Parties
  • Compensation
  • Disclosure

Step 2 – Principal and Agent(s) Information  – Enter:

  • A Principal’s Name
  • A Principal’s Address
  • City
  • State
  • AND
  • An Agent’s name
  • An Agent’s Address
  • City
  • State
  • AND
  • Submit the name of a Successor Agent (Optional)
  • The Successor Agent’s Address
  • City
  • State

Step 3 – Signatures – To be submitted before a Notary Public:

  • Enter the Principal’s printed name
  • Provide a date the Principal’s signature in dd/mm/yyyy format
  • AND
  • The Agent’s printed name
  • Enter the Agent’s Signature
  • Date the Agent’s signature in mm/dd/yyyy format
  • AND
  • The Successor Agent’s printed name
  • The Successor Agent’s signature
  • Date the Successor’s signature in mm/dd/yyyy format

Step 4 – Notarization –

Once the Notary witnesses all signatures, the notary will then enter all of the state requirements that shall prove acknowledgement of the document, to include affixing the official seal.

Step 5 – Acknowledgement and Acceptance of Agents – Agent’s shall read the acknowledgements– Enter the following:

  • Printed names of the Agents
  • Agent’s respective signatures
  • Dates of signatures in mm/dd/yyyy format
  • AND

The Witnesses must first review the Witness Attestation and enter the following:

  • Printed names of the Witnesses
  • Signatures of the Witnesses