Fill and Sign the Power Attorney Form 481374624

AFFIDAVIT OF ATTORNEY-IN-FACT AS TO POWER OF ATTORNEY BEING IN FULL FORCE STATE OF ____________________ COUNTY OF __________________ PERSONALLY appeared before me, __________________________________, hereinafter “Agent”, who being duly sworn by me states upon his or her oath and personal knowledge the following: 1. Agent resides in ___________________ County, ___________________. The Principal, _______________________________________, signed a written Power of Attorney on _______________________________, 20____, appointing Agent as his/her attorney-in-fact. (A true copy of the power of attorney is attached hereto and incorporated herein.) 2. As attorney-in-fact and under and by virtue of the Power of Attorney, Agent has this date executed the following described instrument: ___________________________________________________________________________________________________________________________________. 3. At the time of executing the above described instrument Agent had no actual knowledge or actual notice of revocation or termination of the Power of Attorney by death or otherwise , or notice of any facts indicating the same. 4. Agent represents that the principal is now alive; has not, at any time, revoked or repudiated the power of attorney; and the power of attorney still is in full force and effect. 5. Agent makes this affidavit for the purpose of inducing ___________________________ ___________________ to accept delivery of the above described instrument, as executed by me/us in my/our capacity of attorney(s)-in-fact for the Principal. DATED this the ________ day of _______________, 20_____. Agent___________________________________ Signature Print Name: _________________________ Sworn to and subscribed before me on this the ________ day of _____________________, 20____. _____________________________ Notary Public My Commission Expires:________________________