The following optional form may be used by an agent to certify facts concerning a power of attorney:
I, __________________________ (Name of Agent), do hereby state and affirm the following under penalty of perjury:
(1) _____________________________ (Name of Principal) granted me authority as an agent or successor agent in a power of attorney dated __________.
(2) The powers and authority granted to me in the power of attorney are currently exercisable by me.
(3) I have no actual knowledge of any of the following:
(a) The principal is deceased.
(b) The power of attorney or my authority as agent under the power of attorney has been revoked or terminated, partially or otherwise.
(c) The principal lacked the understanding and capacity to make and communicate decisions regarding his estate and person at the time the power of attorney was executed.
(d) The power of attorney was not properly executed and is not a legal, valid power of attorney.
(e) (Insert other relevant statements) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(4) I agree not to exercise any powers granted under the power of attorney if I become aware that the principal is deceased, that the power of attorney has been revoked or terminated, or that my authority as agent under the power of attorney has been revoked or terminated.
___________________________________ __________________________________
Agent's Signature Date
___________________________________
Agent's Name Printed
___________________________________
Agent's Address
___________________________________
Agent's Telephone Number
COUNTY OF ________________________, STATE OF ____________________________.
Sworn to or affirmed and subscribed before me this day by:
Date: ________________________________ _________________________________
Signature of Notary Public
(Official Seal)
________________________, Notary Public
Printed or typed name
My commission expires: ________________"