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:
______________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________________
(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:
_________________________________________________________________
Utah Code § 75A-2-302