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

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:

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's 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:

   _________________________________________________________

[L 2014, c 22, pt of §1]