Conn. Gen. Stat. § 1-352

(2) “DURABLE STATUTORY POWER OF ATTORNEY - SHORT FORM

Notice: The powers granted by this document are broad and sweeping. They are defined in the Connecticut Uniform Power of Attorney Act, which expressly permits the use of any other or different form of power of attorney desired by the parties concerned. The grantor of any power of attorney or the agent may make application to a Probate Court for an accounting as provided in subsection (d) of section 45a-175 of the general statutes. This power of attorney does not authorize the agent to make health care decisions for you.

Know All Persons by These Presents, which are intended to constitute a GENERAL POWER OF ATTORNEY pursuant to the Connecticut Uniform Power of Attorney Act:

That I .... (insert name and address of the principal) do hereby appoint .... (insert name and address of the agent, or each agent, if more than one is designated) my agent(s) TO ACT .....

If more than one agent is designated and the principal wishes each agent alone to be able to exercise the power conferred, insert in this blank the word ‘severally'. Failure to make any insertion or the insertion of the word ‘jointly' shall require the agents to act jointly.

First: In my name, place and stead in any way which I myself could do, if I were personally present, with respect to the following matters as each of them is defined in the Connecticut Uniform Power of Attorney Act to the extent that I am permitted by law to act through an agent:

(Strike out and initial in the opposite box any one or more of the subparagraphs as to which the principal does NOT desire to give the agent authority. Such elimination of any one or more of subparagraphs (A) to (M), inclusive, shall automatically constitute an elimination also of subparagraph (N).)

To strike out any subparagraph the principal must draw a line through the text of that subparagraph AND write his initials in the box opposite.