2014 Virginia Code
Title 64.2 - Wills, Trusts, and Fiduciaries
§ 64.2-1639. 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/City 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 SignatureDate
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
My commission expires:(Seal, if any)
.............................…
Notary Registration Number: ..........................…
This document prepared by:

........................................................…

2010, cc. 455, 632, § 26-113; 2012, c. 614.