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) 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) ___________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
(Insert other relevant statements)
SIGNATURE AND ACKNOWLEDGMENT
__________________________________ ______________________
Agent 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:
__________________________________________________________________
Source: L. 2009: Entire part added, (HB 09-1198), ch. 106, p. 417, § 1, effective April 9.
OFFICIAL COMMENT
This section provides an optional form that may be used by an agent to certify facts concerning a power of attorney. Although the form contains statements of fact about which persons commonly request certification, other factual statements may be added to the form for the purpose of providing an agent certification pursuant to Section 15-14-719.
SUBPART 4
MISCELLANEOUS PROVISIONS