Fill and Sign the Validity Power Attorney Form

AGENT'S CERTIFICATION AS TO THE VALIDITY OF POWER OF ATTORNEY AND AGENT'S AUTHORITY State of ________________ 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 signature Date ________________________________________ __ Agent's name printed Agent's address __________________________________________ __________________________________________ Age nt's telephone number ________________ This document was acknowledged before me on ______ ____________________ (Date) by __________________________________________ (Name of agent). (Seal, if any) _________________________ ____________ _ Signature of notary My commission expires: This document prepared by: __________________________________________