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(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: _________________________________________________________________