The following optional template may be used by an agent or an attorney at law who represents either the agent or the principal to certify facts concerning a power of attorney:

CERTIFICATION AS TO THE VALIDITY OF POWER OF ATTORNEY AND AGENT'S AUTHORITY
State of _____________________________
[County] of ___________________________
I, _____________________________________________ (Name of Certifier), certify under penalty of perjury that __________________________________________(Name of Principal) granted _____________________________________________ (Name of Agent) 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 the Agent's authority to act under the Power and the Power and the Agent's authority to act under the Power have not otherwise terminated;
(2) If the Power of Attorney was drafted to become effective upon the happening of a specified event or contingency, the specified event or contingency has occurred;
(3) If the Agent was named as a successor agent, the prior agent is unable or unwilling to serve; and
(4)________________________________________________________________________________________________________
(Insert other relevant statements. You may attach separate sheets if additional space is needed.)
SIGNATURE ANDACKNOWLEDGMENT
________________________________	_______________
Certifier's Signature		Date
________________________________
Certifier's Name Printed
________________________________
Certifier's Capacity (as Agent, attorney at law for Agent, or attorney at law for Principal)
________________________________
Certifier's Address
________________________________
Certifier's Telephone Number
This document was acknowledged before me on _______________,
	(Date)
by ____________________________________________.
(Name of Certifier)
________________________________	(Seal, if any)
Signature of Notary
My commission expires: _______________
This document prepared by:
__________________________________________________________________