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/City 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's Signature

____________________Date

Agent's Name Printed________________________________________

________________________________________ Agent's Address

________________________________________Agent's Telephone Number

This document was acknowledged before me on ____________________ (Date), by ____________________ (Name of Agent).________________________________________ Signature of Notary

My commission expires: ____________________ (Seal, if any)

Notary Registration Number: ____________________

This document prepared by:

________________________________________

2010, cc. 455, 632, § 26-113; 2012, c. 614.