The following optional form may be used by an agent to certify facts concerning a power of attorney. AGENT'S CERTIFICATION AS TO THE VALIDITY OF POWER OF ATTORNEY AND AGENT'S AUTHORITY S t a t e o f _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ C o u n t y o f __________________________________ I, __________________________________ (Name of agent), certify under penalty of perjury that __________________________________ (Name of principal) granted me authority as an agent or successor agent in a power of attorney dated __________________________________. I further certify that to my knowledge: (1) The principal is alive and has not revoked the power of attorney or my authority to act under the power of attorney and the power of attorney and my authority to act under the power of attorney have not terminated; (2) If the power of attorney was drafted to become effective upon the happening of an event or contingency, the event or contingency has occurred; (3) If I was named as a successor agent, the prior agent is no longer able or willing to serve; and (4) ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ (Insert other relevant statements) SIGNATURE AND ACKNOWLEDGMENT _______________________ _____________ Agent signature Date _______________________ Agent's name printed _______________________ _______________________ Agent's address _______________________ Agent's telephone number This document was acknowledged before me on ________________________, (Date) by ________________________. (Name of agent) __________________________ (Seal, if any) Signature of notary My commission expires:________________________ This document prepared by: ___________________________________________
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