(c) A written affidavit executed by the agent under this subsection which may, but need not, be in the following form:STATE OF
COUNTY OF
Before me, the undersigned authority, personally appeared (agent) (“Affiant”) by the means specified herein, who swore or affirmed that:
1. Affiant is the agent named in the Power of Attorney executed by (principal) (“Principal”) on (date) .
2. This Power of Attorney is currently exercisable by Affiant. The principal is domiciled in (insert name of state, territory, or foreign country) .
3. To the best of Affiant’s knowledge after diligent search and inquiry:
a. The Principal is not deceased;
b. Affiant’s authority has not been suspended by initiation of proceedings to determine incapacity or to appoint a guardian or a guardian advocate;
c. Affiant’s authority has not been terminated by the filing of an action for dissolution or annulment of Affiant’s marriage to the principal, or their legal separation; and
d. There has been no revocation, or partial or complete termination, of the power of attorney or of Affiant’s authority.
4. Affiant is acting within the scope of authority granted in the power of attorney.
5. Affiant is the successor to (insert name of predecessor agent) , who has resigned, died, become incapacitated, is no longer qualified to serve, has declined to serve as agent, or is otherwise unable to act, if applicable.
6. Affiant agrees not to exercise any powers granted by the Power of Attorney if Affiant attains knowledge that the power of attorney has been revoked, has been partially or completely terminated or suspended, or is no longer valid because of the death or adjudication of incapacity of the Principal.
(Affiant)
Sworn to (or affirmed) and subscribed before me by means of ☐ physical presence or ☐ online notarization this day of (month) , (year) , by (name of person making statement) .
(Signature of Notary Public)
(Print, Type, or Stamp Commissioned Name of Notary Public)
Personally Known OR Produced Identification
(Type of Identification Produced)