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

   ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ (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 _______________,

4. (Date) by ______________________________________.

   (Name of Agent)

   _________________________________________

   Signature of Notary

   (Seal, if any)

   My commission expires: ________________________

   [This document prepared by:_____________________________________]