[§551E‑52]  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 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)

    _________________________________   (Seal, if any)

     Signature of Notary

     My commission expires: _________________________

     This document prepared by:

    _________________________________________________________

     [L 2014, c 22, pt of §1]