2015 West Virginia Code
CHAPTER 39B. UNIFORM POWER OF ATTORNEY ACT
ARTICLE 3. STATUTORY FORMS.
§39B-3-102. 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

_________________________________________________________________ _________________________________________________________________ _________________________________________________________________ (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: ________________________

[This document prepared by:_____________________________________]