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 Maryland (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:
____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(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:
______________________________________________________________________________."
Md. Code, ET § 17-204