I，__(1)__，of__(2)__，hereby appoint__(3)__，of__(4)__，as my attorney in fact to act in my capacity to do every act that I may legally do through an attorney in fact. This power shall be in full force and effect on the date below written and shall remain in full force and effect until__(5)__or unless specifically extended or rescinded earlier by either party.
我，__(姓名)，__(地址等)，在此指定__(姓名)，__(地址或律师事务所名称等)，为我的律师，以我的身份履行一切实践中我通过律师所能从事的合法行为。本权利在以下载明日期全权生效并一直持续到__或持续到双方当事人规定的延展期或提前撤销期。
Dated__(6)__，20_(7)_。 __(8)__
STATE OF__(9)__ (签名处)
COUNTY OF__(10)__
日期：__
地址：__
州名和县名：__