Form E34r Sample - Power Of Attorney (Real Estate)

Form E34r Sample - Power Of Attorney (Real Estate) - 2009 Page 3

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

__________________________________________

_____________________________________________________

Date

Agent’s signature

Print agent’s name: __________________________________

Agent’s Address: ____________________________________

_____________________________________________________

Agent’s telephone number: ____________________________

State of ___________________________

County of _________________________

This document was acknowledged before me on _____________________________________________, (date) by

__________________________________________________________. (Name of Agent)

_____________________________________________________

Signature of notary

My commission expires: ______________________________

No. e34R. Rev. 11-09.

POWER OF ATTORNEY (REAL ESTATE)

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Form E34r Sample - Power Of Attorney (Real Estate) - 2009 Page 3