10-6B-71. Optional form for agent certification of facts.

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 Georgia

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:

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;#

If the power of attorney was drafted to become effective upon the happening of an event or contingency, the event or contingency has occurred;#

If I were named as a successor agent, the prior agent is no longer able or willing to serve; and#

1. (Insert other relevant statements)

2. SIGNATURE AND ACKNOWLEDGMENT

3. Agent’s signature Date

4. Agent’s name printed

5. Agent’s address

6. Agent’s telephone number

7. Agent’s email address

8. This document was signed in my presence on , by

9. (Date)

10. (Name of agent)

11. (Seal)

12. Signature of notary

13. My commission expires:

14. This document prepared by: .