2012 Arkansas Code
Title 28 - Wills, Estates, and Fiduciary Relationships
Subtitle 5 - Fiduciary Relationships
Chapter 68 - Uniform Power of Attorney Act
Subchapter 3 - -- Statutory Forms
§ 28-68-302 - 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)

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: _________________