Iowa Code § 633B.302

The following optional form may be used by an agent to certify facts concerning a power of attorney:

IOWA STATUTORY POWER OF ATTORNEY AGENT’S CERTIFICATION FORM

AGENT’S CERTIFICATION OF 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 all of the following to my knowledge:

The principal is alive and has not revoked the power of attorney or the power of attorney and my authority to act under the power of attorney have not terminated.

If the power of attorney was drafted to become effective upon the happening of an event or contingency, the event or contingency has occurred.

If I was named as a successor agent, the prior agent is no longer able or willing to serve.

__________________________________________________________

__________________________________________________________

__________________________________________________________.

(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

___________________________________________________________

___________________________________________________________