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 Statement(s)).

   SIGNATURE AND ACKNOWLEDGMENT

   Agent's Signature: ________________________________________

   Date: __________________________________________________

   Agent's Name Printed ___________________________________

   Agent's Address ________________________________________

   Agent's Telephone Number ______________________________

   Signed and sworn to (or affirmed) before me on _______________ , by _______________ , known to me or satisfactorily proven to be the person named herein

   Signature of Notarial Officer:

   Title (and Rank):

   My commission expires:

AGENT'S CERTIFICATION AS TO THE VALIDITY OF POWER OF ATTORNEY AND AGENT'S AUTHORITY

STATE OF NEW HAMPSHIRE

COUNTY OF _______________

I, _______________ , certify under penalty of perjury that _______________ granted me authority as an agent in a power of attorney dated _______________ .

I further certify that to my knowledge:

Source. 2017, 178:1, eff. Jan. 1, 2018.