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:
(Insert other relevant statements)
SIGNATURE AND ACKNOWLEDGMENT
____________________________________________ _______________
Agent's SignatureDate
____________________________________________
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: _________________________________________
Added by Laws 2021, c. 332, § 42, eff. Nov. 1, 2021.