[§551E‑52] Agent's certification. 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'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:
_________________________________________________________
[L 2014, c 22, pt of §1]