Fill and Sign the Power Attorney Form 497426505

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: ________________________