2017 Georgia Code
Title 10 - Commerce and Trade
Chapter 6B - Uniform Power of Attorney
Article 3 - Statutory Forms
§ 10-6B-71. Optional form for agent certification of facts
- 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 Georgia
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 were named as a successor agent, the prior agent is no longer
able or willing to serve; and
- (4) ____
- (1) The principal is alive and has not revoked the power of attorney or
- ____
____
____
____
(Insert other relevant statements)
SIGNATURE AND ACKNOWLEDGMENT
____ ____
Agent's signature Date
____
Agent's name printed
____
____
Agent's address
____
Agent's telephone number
____
Agent's e-mail address
This document was signed in my presence on____,
(Date)
by ____.
(Name of agent)
____ (Seal)
Signature of notary
My commission expires: ____
This document prepared by: ____.
