2015 Connecticut General Statutes
Title 1 - Provisions of General Application
Chapter 15c - Connecticut Uniform Power of Attorney Act
Section 1-352a - (Note: This section is effective July 1, 2016.) 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 false statement 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 Commissioner of Superior Court/Notary)
My commission expires:________________________

(P.A. 15-240, S. 42.)

History: P.A. 15-240 effective July 1, 2016.