Certificate Of Authenticity Poa
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1Certificate Authenticating Copy
MoDOT & Patrol Employees’ Retirement System
PO Box 1930 Jefferson City, MO 65102-1930
Of Power of Attorney
Phone: (573) 298-6080 (800) 270-1271
1.
Complete all sections of the form.
Fax: (573) 522-6111 Email: mpers@modot.mo.gov
2.
Sign and date form in the presence of a Notary Public.
Website:
3.
Return the form to MPERS with Power of Attorney.
I ________________________________________________, hereby certify that the attached power of attorney
(Print name of Attorney-in-Fact)
(POA) numbering __________________ pages constitutes a true, correct and complete copy of an original
(Number of pages)
POA granted by _____________________________________________. The signature appearing on the original
(Print name of Principal granting the POA)
POA is the genuine signature of the principal. I have not received any notice modifying or terminating the POA.
To the best of my knowledge, the principal is alive and the attached POA is in full force and effect.
IN WITNESS WHEREOF, I have executed this certificate this _____ day of __________________, __________.
(month)
(year)
_______________________________________
(Signature of Attorney-in-Fact)
County of _________________________ )
) SS
State of ___________________________ )
On this _________ day of ______________________, __________, before me the undersigned, a Notary Public,
in and for the County and State aforesaid, personally appeared to me known to be the person described in and who
executed the foregoing instrument, and acknowledged that he/she executed the same as his/her free act and deed.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed my official seal in _________________
County, State of ___________________________, where I am commissioned, the day and year last above
written.
_______________________________________
(Signature of Notary Public)
9/15
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