The following optional form may be used by an agent to certify facts concerning a power of attorney.
State of Georgia
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) 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) 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) If I were named as a successor agent, the prior agent is no longer able or willing to serve; and
(4)
(Insert other relevant statements)
Agent’s signature Date
Agent’s name printed
Agent’s address
Agent’s telephone number
Agent’s email address
This document was signed in my presence on __—_—7. by (Date)
(Name of agent) (Seal)
Signature of notary
My commission expires:
This document prepared by: