Fill and Sign the Certification Validity Power Form

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 ________________________________ Agent's Signature Date: ___________________________ Agent's Name Printed: ___________________________ Agent's Address: ___________________________ Agent's Telephone Number: ___________________________ This document was acknowledged before me on ___________________________ (Date) by ___________________________ (Name of Agent) ____________________________________ (Seal, if any) Signature of Notary My commission expires: __________________ [This document prepared by: ___________________________ ]