Fill and Sign the Kentucky Affidavit Form

AFFIDAVIT (KRS 384-020) STATE OF ____________________________ COUNTY OF ____________________________ Before me, the undersigned authority, personally appeared ____________________________ (attorney in fact/"Affiant"), who swore or affirmed that: 1. Affiant is the attorney in fact named in the Durable Power of Attorney executed by ____________________________ ("Principal") on __________________ (date) . 2. To the best of Affiant's knowledge after diligent search and inquiry: (a) The Principal is not deceased, has not been adjudicated incapacitated, and has not revoked, partially or completely terminated, or suspended the Durable Power of Attorney; and (b) The Affiant has no actual knowledge of the revocation or termination of the power of attorney, by death, disability or incompetence. 3. Affiant agrees not to exercise any powers granted by the Durable Power of Attorney if Affiant attains knowledge that it has been revoked, partially or completely terminated, suspended, or is no longer valid because of the death or adjudication of incapacity of the Principal. ________________________________________ Affiant STATE OF ____________________________ ____________________________ County Before me, the undersigned authority, came the grantor who is of sound mind and eighteen (18) years of age, or older, and acknowledged that he voluntarily dated and signed this writing or directed it to be signed and dated as above. Done this       day of ____________________________ , 20       . ________________________________________________________ Signature of Notary Public or other officer. Date commission expires: ____________________________