Form F-00036 - Designation Of Agent Page 8
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15The following optional form may be used by an agent to certify facts
concerning a power of attorney for finances and property:
AGENT’S CERTIFICATION AS TO THE VALIDITY OF
POWER OF ATTORNEY FOR FINANCES AND PROPERTY 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.
(4)
(insert other relevant statements)
SIGNATURE AND ACKNOWLEDGMENT
Agent’s signature
Date
Agent’s name printed
Agent’s address:
Agent’s telephone number:
State of:
County of:
This document was acknowledged before me on
Date
by (name of agent)
(Seal, if any)
Signature of notary
Name of notary (typed or printed)
My commission expires:
This document prepared by:
Page 7
Wisconsin Power of Attorney for Finances and Property
F-00036 (Rev. 09/10)
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