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 on 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)

   (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

   ___________________________________________,

   (Date)

   by________________________________________.

   (Name of Agent).

   ___________________________________________

   (Seal, if any)

   Signature of Notary

   My commission expires: ____________________

   This document prepared by: __________.”

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 Maryland

(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:

Added by Acts 2010, c. 689, § 1, eff. Oct. 1, 2010; Acts 2010, c. 690, § 1, eff. Oct. 1, 2010.