Fill and Sign the Maryland Agent Form

AGENT'S CERTIFICATION AS TO THE VALIDITY OF POWER OF ATTORNEY AND AGENT'S AUTHORITY State of Maryland 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 th e 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 p repared by: _______________________