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Fill and Sign the Validity Power Attorney 497317187 Form

Fill and Sign the Validity Power Attorney 497317187 Form

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AGENT'S CERTIFICATION AS TO THE VALIDITY OF POWER OF ATTORNEY AND AGENT'S AUTHORITY (G.S. 32C-3-302) I, ________________________________________ (Name of Agent), do hereby state and affirm the following under penalty of perjury: (1) ________________________________________ (Name of Principal) granted me authority as an agent or successor agent in a power of attorney dated _________________________________ . (2) The powers and authority granted to me in the power of attorney are currently exercisable by me. (3) I have no actual knowledge of any of the following: (a) The principal is deceased. (b) The power of attorney or my authority as agent under the power of attorney has been revoked or terminated, partially or otherwise. (c) The principal lacked the understanding and capacity to make and communicate decisions regarding his estate and person at the time the power of attorney was executed. (d) The power of attorney was not properly executed and is not a legal, valid power of attorney. (e) (Insert other relevant statements) ______________________________________________ ____________________________________________________________________________ (4) I agree not to exercise any powers granted under the power of attorney if I become aware that the principal is deceased, that the power of attorney has been revoked or terminated, or that my authority as agent under the power of attorney has been revoked or terminated. SIGNATURE AND ACKNOWLEDGMENT _______________________________________________ Agent's Signature Date ____________________________ ________________________________________ Agent's Name Printed ______________________________________________ ______________________________________________ Agent's Address ______________________________________________ Agent's Telephone Number COUNTY OF ________________________________________ , STATE OF ________________________________________ . Sworn to or affirmed and subscribed before me this day by: Date: ________________________________ _____________________________________________ Signature of Notary Public (Official Seal) ________________________________________ , Notary Public Printed or typed name My commission expires: ________

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