The following optional form may be used by an agent to certify facts concerning a power of attorney:
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) 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 was named as a successor agent, the prior agent is no longer able or willing to serve; and
(4) _____________________________________________________________________________
___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
Agent's Signature: ________________________ ________________________ (Date)
Agent's Name Printed: _______________________________________
Agent's Address: ___________________________
____________________________________________
Agent's Telephone Number: __________________
This instrument was acknowledged before me on _____________________ (Date)
by ______________________________________ (Name of Agent).
Signature of notarial officer: _________________________________________
(Seal, if any)
My commission expires: ________________________.".