§ 64-2-1639

The following optional form may be used by an agent to certify facts concerning a power of attorney.\nAGENT'S CERTIFICATION AS TO THE VALIDITY OF POWER OF ATTORNEY AND AGENT'S AUTHORITY\nState of ____________________\nCounty/City of ____________________\nI, ____________________ (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 ____________________.\nI further certify that to my knowledge:\n(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;\n(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;\n(3) If I was named as a successor agent, the prior agent is no longer able or willing to serve; and\n(4) ____________________________________\n________________________________________\n________________________________________\n________________________________________\n(Insert other relevant

ve; and\n(4) ____________________________________\n________________________________________\n________________________________________\n________________________________________\n(Insert other relevant statements)\nSIGNATURE AND ACKNOWLEDGMENT\n________________________________________\nAgent's Signature\n____________________\nDate\nAgent's Name Printed\n________________________________________\n________________________________________\nAgent's Address\n________________________________________\nAgent's Telephone Number\nThis document was acknowledged before me on ____________________ (Date), by ____________________ (Name of Agent).\n________________________________________\nSignature of Notary\nMy commission expires: ____________________ (Seal, if any)\nNotary Registration Number: ____________________\nThis document prepared by:\n________________________________________\n2010, cc. 455, 632, § 26-113; 2012, c. 614.