§ 1337.61

Effective: March 22, 2012 Latest Legislation: Senate Bill 117 - 129th General Assembly 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 AUTHORITYState of OhioCounty 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

afted 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;(4)_______________________________________________________________________________________________________________________________________________________________________________________(Insert other relevant statements).SIGNATURE AND ACKNOWLEDGMENT___________________________________Agent's Signature ___________________________________Date________________________________________________________________Agent's Name Printed________________________________________________________________Agent's Address________________________________________________________________Agent's Telephone NumberState of OhioCounty of __________________________This document was acknowledged before me on______________________,(Date) by _______________________(Name of Agent).________________________________Signature of NotaryMy commission expires:_________________________________This document prepared by:__________________________________________________________________