Power of Attorney form

PDF Version

Power of Attorney Form
Word Version
74 KB, 1 page

Power of Attorney Form
PDF Version
45 KB, 1 page

space to insert name and address of firm making claim
(Name and address of firm submitting claim)

Power of Attorney — To Recover Unclaimed Dividends

  1. space to insert name of Individual/Company named as Power of Attorney (Name of Individual/Company named as Power of Attorney) has determined that an unclaimed dividend from the estate of space to insert name of insolvent (Name of insolvent and estate number), for the sum of $ space to insert sum, was sent to the Receiver General for Canada for the following payee:space to insert name
    space to insert name (Name and address of payee).
  2. space to insert Name of Individual/Company named as Power of Attorney (Name of Individual/Company named as Power of Attorney) is hereby appointed as attorney for space to insert Name of creditor (Name of creditor) for the single purpose of collecting this account on behalf of the payee.
  3. The Receiver General for Canada is instructed to forward a cheque for the amount of the dividend, payable to space to insert Name of Power of Attorney (Name of Power of Attorney) in trust.
  4. Upon receipt of the funds from the Receiver General for Canada, space to insert Name of Power of Attorney
    space to insert Name of Power of Attorney(Name of Power of Attorney) will immediately forward the funds to the creditor, minus the agreed upon fee.
space to insert Name of Creditor
Creditor's signature
space to insert name of Authorized Power of Attorney
Authorized Power of Attorney's signature
space to print name and address of creditor
Print name
space to print name and address of Authorized Power of Attorney
Print name
space to print name and address of Authorized Power of Attorney
Address
space to print name and address of Authorized Power of Attorney
Address
space to insert title and position held by creditor
Title and position held
space to insert title and position held by Authorized Power of Attorney
Title and position held
space to insert Date
Date
space to insert Date
Date
space to insert Witness name
Witness' signature
space to insert Address of subscribing witness
Print name
space to insert Address of subscribing witness
Address

space to insert Date
Date

Date modified: