§ 17-204

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 Maryland
(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 on 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 prepared by:

______________________________________________________________________________.”