Section 26-1A-302

Agent's certification.

A document substantially in the following format 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:

___________________________________________]

(Act 2011-683, p. 2015, §1.)