Whenever this chapter requires or permits a
custodian or other person to make an affidavit of regularity with respect
to an electronic power of attorney or a complete converted copy, the
custodian or other person responsible for the creation of the affidavit
of regularity may use the following format for the affidavit:
"Affidavit of Regularity of Electronic Power of Attorney
(1)Beginning on (insert date of first possession of the electronic
power of attorney by the signer of this affidavit) and continuing
to the date and time of this affidavit, the undersigned person has
had possession of (circle all of the following that apply):
(A)The electronic record for the electronic power of attorney.
(B)A complete converted copy of the electronic power of
attorney of (insert name of principal),
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Whenever this chapter requires or permits a
custodian or other person to make an affidavit of regularity with respect
to an electronic power of attorney or a complete converted copy, the
custodian or other person responsible for the creation of the affidavit
of regularity may use the following format for the affidavit:
"Affidavit of Regularity of Electronic Power of Attorney
(1) Beginning on (insert date of first possession of the electronic
power of attorney by the signer of this affidavit) and continuing
to the date and time of this affidavit, the undersigned person has
had possession of (circle all of the following that apply):
(A) The electronic record for the electronic power of attorney.
(B) A complete converted copy of the electronic power of
attorney of (insert name of principal), which was electronically
executed on (insert date of electronic signing or insert reference
to time stamp).
(2) (Insert client number, customer number, document number, or
other unique identifier as applicable) is the unique identifier that
the undersigned person assigned to this electronic power of
attorney in the undersigned person's records.
(3) The undersigned person believes that the principal (circle one
(1) of the following options):
(A) Is alive.
(B) Died on or about (insert date of death) and the undersigned
person believes that the power of attorney is currently (circle
one (1) of the following options):
(i) In effect.
(ii) Not in effect.
(4) The undersigned person is (circle all of the following that
apply):
(A) Transferring custody of the electronic record for the
electronic power of attorney to the living principal of the
electronic power of attorney.
(B) Transferring custody of the electronic record for the
electronic power of attorney to (insert name and address of
successor custodian).
(C) Transferring a complete converted copy of the electronic
power of attorney to (insert name and address of authorized
recipient).
(5) The undersigned person is transferring or submitting the
electronic record in the following format: (specify format).
(6) If the undersigned person is transferring or submitting the
electronic record for the electronic power of attorney, the
undersigned person affirms, under penalty of perjury, that the
electronic record has been in the undersigned person's possession
or control for the period stated in paragraph (1) and that during
this period, the electronic record showed no indication of
unauthorized alteration or tampering.
(7) The undersigned person affirms, under penalty of perjury, that
(circle one (1) of the following options):
(A) The undersigned person has no knowledge of the principal's
later execution of any document that amends, revokes, or
supersedes the electronic power of attorney described in
paragraph (1).
(B) The undersigned believes that the principal purportedly
amended or revoked the electronic power of attorney described
in paragraph (1) on (insert date if known or approximate time
frame if date is not known), by (insert known details concerning
the principal's amendment or revocation).
(8) The undersigned person is (circle all of the following that
apply):
(A) The living principal who executed the electronic power of
attorney.
(B) An attorney admitted to practice law in the state of Indiana.
(C) A currently serving attorney in fact appointed under or
named in the explicit terms of the electronic power of attorney.
(D) A successor attorney in fact nominated by the electronic
power of attorney.
(E) A custodian currently in compliance with all applicable
requirements.
(9) (Insert date and time of the custodian's or other person's
signature).
(10) (Insert name and signature of custodian or other person
signing. Insert job title or position of signatory if signatory is not
an individual (natural person)).".