Vermont § 4053 - Agent’s certification The following optional form may be used by an agent to certify facts concerning a power of attorney

§ 4053. Agent’s certification 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 below) ----------------- _________________________________________ ----------------- _________________________________________ ----------------- _________________________________________ ----------------- _________________________________________ ----------------- _________________________________________ SIGNATURE AND ACKNOWLEDGMENT ----------------- _________________________________________ Agent’s Name Printed _______________________________________________________________________ Agent’s Address _______________________________________________________________________ Agent’s Telephone Number _______________________________________________________________________ This document was acknowledged before me on (Date) _________________________________________ by _______________________________________________________________________ (Name of Agent) _______________________________________________________________________Signature of Notary (Seal, if any) My commission expires: _________________________________________ (Added 2023, No. 60, § 1, eff. July 1, 2023.)