§ 457.430

457.430 Agent’s certification. The following optional form may be used by an agent to certify facts concerning a power of attorney: 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 Attor ney 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 willin g to serve; and (4)_____________________________________________________________________

contingency has occurred; (3) If I was named as a successor agent, the prior agent is no longer able or willin g 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 docume nt was acknowledged before me on __________________________, (Date) by______________________________________. (Name of Agent) ____________________________________________ (Seal, if any) Signature of Notary My commission expires: _________________ _______ This document prepared by:

__________________________. (Name of Agent) ____________________________________________ (Seal, if any) Signature of Notary My commission expires: _________________ _______ This document prepared by: _________________________________________________________________ Effective: July 15, 2020 History: Created 2020 Ky. Acts ch. 41, sec. 62, effective July 15, 2020.