§ 21–2603.02. 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

"District of Columbia ________________________

"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 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 Notary

My commission expires: __________________________

This document was prepared by: ___________________________________________________________."