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
S t a t e o f _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ C o u n t y o f
__________________________________
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:
The principal is alive and has not revoked the power of attorney or my authority toact under the power of attorney and 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 anevent 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 toserve; and
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
(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.
SUBPART 4
MISCELLANEOUS PROVISIONS