Agents Certification As To The Validity Of Power Of Attorney And

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AGENT'S   C ERTIFICATION   A S   T O   T HE   V ALIDITY   O F   P OWER   O F   A TTORNEY   A ND  
AGENT'S   A UTHORITY  
 
State   o f   . ......................................................  
 
County   o f   . ...................................................  
I,   . ......................................................................(Name   o f   A gent),   c ertify   u nder   p enalty   o f  
perjury   t hat   . ...................................................................(Name   o f   P rincipal)   g ranted   m e  
authority   a s   a n   a gent   o r   s uccessor   a gent   i n   a   p ower   o f   a ttorney   d ated  
....................................   .  
 
I   f urther   c ertify   t hat   t o   m y   k nowledge:  
 
(1)   T he   P rincipal   i s   a live   a nd   h as   n ot   r evoked   t he   P ower   o f   A ttorney   o r   m y   a uthority  
to   a ct   u nder   t he   P ower   o f   A ttorney   a nd   t he   P ower   o f   A ttorney   a nd   m y   a uthority   t o  
act   u nder   t he   P ower   o f   A ttorney   h ave   n ot   t erminated;  
 
(2)   I f   t he   P ower   o f   A ttorney   w as   d rafted   t o   b ecome   e ffective   u pon   t he   h appening   o f  
an   e vent   o r   c ontingency,   t he   e vent   o r   c ontingency   h as   o ccurred;  
 
(3)   I f   I   w as   n amed   a s   a   s uccessor   a gent,   t he   p rior   a gent   i s   n o   l onger   a ble   o r   w illing  
to   s erve;   a nd  
 
(4)  
 
................................................................................................................................  
................................................................................................................................  
................................................................................................................................  
................................................................................................................................  
(Insert   o ther   r elevant   s tatements)  
SIGNATURE   A ND   A CKNOWLEDGMENT  
................................................................  
.............................  
Agent's   S ignature  
Date  
...................................................................  
Agent's   N ame   P rinted  
...................................................................  
Agent's   A ddress  
...................................................................  
Agent's   T elephone   N umber  
This   d ocument   w as   a cknowledged   b efore   m e   o n   . .................................................  
(Date)  
by   . ......................................................  
(name   o f   A gent)  
...................................................................   ( Seal,   i f   a ny)  
Signature   o f   N otary/Attorney  
My   c ommission   e xpires:   . ......................................................  
This   d ocument   p repared   b y:   . ...................................................................  

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