The following optional form may be used by an agent to certify facts concerning a power of attorney.

1. (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. (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. (3) If I was named as a successor agent, the prior agent is no longer able or willing to serve; and

4. (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 ________________________,

5. (Date) by ________________________.

   (Name of agent)

   __________________________ (Seal, if any)

   Signature of notary

   My commission expires:________________________

   This document prepared by:

   ___________________________________________

AGENT'S CERTIFICATION AS TO THE VALIDITY OF

POWER OF ATTORNEY AND AGENT'S AUTHORITY

State of __________________________________ County of __________________________________

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:

Source: L. 2009: Entire part added, (HB 09-1198), ch. 106, p. 417, § 1, effective April 9.