*03EN010E-001* OKLAHOMA DEPARTMENT OF HUMAN SERVICES Special Power of Attorney I, Type or print your name (principal) Family group number (FGN) residing at: Address City State Zip hereby appoint Name of person you are appointing to be your authorized representative of Address City State Zip as my Attorney-in-Fact (authorized representative). My authorized representative shall have full power and authority to act on my behalf but only to the extent permitted by this Special Power of Attorney. CHECK ONLY THE APPROPRIATE BOX BELOW THAT APPLIES My authorized representative's powers shall include the power to: Obtain information or documents from the Child Support Enforcement Division (CSED) regarding the child support case with the above-listed FGN. OR Obtain information or documents from CSED regarding the child support case with the above-listed FGN. Take any and all legal steps necessary to negotiate, compromise, or settle the child support case with the above-listed FGN with any governmental body or agency (including tax matters), including the power to sign releases and agreements and to prepare, sign, and file documents with any governmental body or agency, as fully as I could do if personally present and acting. This Special Power of Attorney does not confer to my authorized representative the right to appear in district court or Office of Administrative Hearings: Child Support on my behalf. My authorized representative shall not be liable for any loss that results from a judgment error that was made in good faith. My authorized representative shall be liable for willful misconduct or the failure to act in good faith while acting under the authority of this Special Power of Attorney. I authorize my authorized representative to indemnify and hold harmless any third party who accepts and acts under this document. My authorized representative shall provide an accounting for all funds handled and all acts performed as my authorized representative, if I so request or if such a request is made by any authorized personal representative or fiduciary acting on my behalf. I understand I may have only one authorized representative at any time. This Special Power of Attorney shall become effective immediately, and shall not be affected by my disability or lack of mental competence, except as may be provided otherwise by an applicable state statute. This is a Durable Power of Attorney. This Special Power of Attorney shall continue effective until my death. CSED considers this designation in effect until CSED receives a new Form 03EN010E, Special Power of Attorney, designating another individual as the authorized representative, or written notice that this Special Power of Attorney is revoked. This Special Power of Attorney may be revoked by me at any time. Principal's signature OKDHS revised 3-15-2004 Date 03EN010E (CSED-10) American LegalNet, Inc. www.FormsWorkflow.com 03EN010E (CSED-10) Special Power of Attorney The principal is personally known to me and I believe the principal to be of sound mind. I am eighteen years of age or older. I am not related to the principal by blood or marriage, or related to the attorney-in-fact by blood or marriage. The principal has declared to me that this instrument is his or her power of attorney, granting to the named attorney-in-fact the power and authority specified herein, and that he or she has willingly made and executed it as his or her free and voluntary act for the purposes herein expressed. Witness signature STATE OF OKLAHOMA COUNTY OF Date Witness signature Date ) ss ) Before me, the undersigned authority, on this day of , 20 personally appeared (principal) and (witness) and (witness), whose names are subscribed to the foregoing instrument in their respective capacities, and all of said persons being by me duly sworn, the principal declared to me and to the said witnesses in my presence that the instrument is his or her power of attorney, and that the principal has willingly and voluntarily made and executed it as the free act and deed of the principal for the purposes therein expressed, and the witnesses declared to me that they were each eighteen years of age or over, and that neither of them is related to the principal by blood or marriage, or related to the attorney-in-fact by blood or marriage. Notary public My commission number My commission expires This completed and notarized document must be returned to your local child support office BEFORE anyone from the Child Support Enforcement Division (CSED) will be able to speak with your authorized representative about your case. Once received, it will remain in effect until CSED is notified IN WRITING of its revocation, or until CSED receives a new Form CSED-10, Special Power of Attorney, designating another individual as the authorized representative. 2 OKDHS revised 3-15-2004 American LegalNet, Inc. www.FormsWorkflow.com