AFFIDAVIT
O F
A GENT
F ORM
STATE
O F
_ ______________
COUNTY
O F
_ _____________
Before
m e,
t he
u ndersigned
a uthority,
p ersonally
a ppeared
_ ________________
( agent)
(“Affiant”),
w ho
s wore
o r
a ffirmed
t hat:
1.
Affiant
i s
t he
a gent
n amed
i n
t he
P ower
o f
A ttorney
e xecuted
b y
_ ________________
(“Principal”)
o n
_ ______________
( date).
2.
This
P ower
o f
A ttorney
i s
c urrently
e xercisable
b y
A ffiant.
T he
p rincipal
i s
domiciled
i n
_ _______________
( insert
s tate,
t erritory,
o r
f oreign
c ountry).
3.
To
t he
b est
o f
t he
A ffiant’s
k nowledge
a fter
d iligent
s earch
a nd
i nquiry:
The
P rincipal
i s
n ot
d eceased;
Affiant’s
a uthority
h as
n ot
b een
s uspended
b y
i nitiation
o f
p roceedings
t o
d etermine
incapacity
o r
t o
a ppoint
a
g uardian
o r
g uardian
a dvocate;
a nd
There
h as
b een
n o
r evocation,
p artial
o r
c omplete
t ermination
o f
t he
P ower
o f
Attorney
o r
o f
A ffiant’s
a uthority.
4.
A ffiant
i s
a cting
w ithin
t he
s cope
o f
a uthority
g ranted
i n
t he
P ower
o f
A ttorney.
5.
A ffiant
a grees
n ot
t o
e xercise
a ny
p owers
g ranted
b y
t he
P ower
o f
A ttorney
i f
Affiant
a ttains
k nowledge
t hat
i t
h as
b een
r evoked,
p artially
o r
c ompletely
terminated
o r
s uspended,
o r
i s
n o
l onger
v alid
b ecause
o f
t he
d eath
o r
a djudication
of
i ncapacity
o f
t he
P rincipal.
_________________________
(Affiant)
Sworn
t o
( or
a ffirmed)
a nd
s ubscribed
b efore
m e
t his
t he
_ ___
d ay
o f
_ __________
(month),
_ _______
( year),
b y
_ ________________
( Affiant)
____________________________________
(Signature
o f
N otary
P ublic-‐
S tate
o f
F lorida)
(Print,
T ype,
o r
S tamp
C ommissioned
N ame
o f
N otary
P ublic)
Personally
K nown
O R
P roduced
I dentification
_ _____________________________
(Type
o f
I dentification
P roduced)