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'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).
   ________________________________________
   Signature of Notary

   My commission expires: ____________________ (Seal, if any)

   Notary Registration Number: ____________________

   This document prepared by:

   ________________________________________

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

State of ____________________

County/City 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:

2010, cc. 455, 632, § 26-113; 2012, c. 614.