Statute text
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
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:
 
History
Source: L. 2009: Entire part added, (HB 09-1198), ch. 106, p. 417, 1, effective April 9.
Annotations
OFFICIAL COMMENT
This section provides an optional form that may be used by an agent to certify facts concerning a power of attorney. Although the form contains statements of fact about which persons commonly request certification, other factual statements may be added to the form for the purpose of providing an agent certification pursuant to Section 15-14-719.