Fill and Sign the I Name of Agent Certify under Penalty of Perjury that Form

AGENT'S CERTIFICATION AS TO THE VALIDITY OF POWER OF ATTORNEY AND AGENT'S AUTHORITY State of New Mexico 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/Attorney My commission expires: ________________ This document prepared by:_______________________