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) I am acting in good faith pursuant to the authority given under the power of attorney;

(2) The principal is alive and has not terminated, revoked, limited, or modified the power of attorney or my authority to act under the power of attorney; nor has the power of attorney or my authority to act under the power of attorney been terminated, revoked, limited, or modified by any other circumstances;

(3) When the power of attorney was signed, the principal was competent to execute it and was not under undue influence to sign;

(4) All events necessary to making the power of attorney effective have occurred;

(5) If I was married or a registered domestic partner of the principal when the power of attorney was executed, there has been no subsequent dissolution, annulment, or legal separation, and no action is pending for the dissolution of the marriage or domestic partnership or for legal separation;

(6) If the power of attorney was drafted to become effective upon the happening of an event or contingency, the event or contingency has occurred;

(7) If I was named as a successor agent, the prior agent is no longer able or willing to serve, or the conditions stated in the power of attorney that cause me to become the acting agent have occurred; and

(8) _____

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_____

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(Insert other relevant statements)

_____

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)

_____

Signature of Notary

(Seal, if any)

My commission expires: _____

[This document prepared by:

_____]