HRS §551E-52
Optional form for an agent to certify a power of attorney
This section provides an optional form an agent can use to certify facts about a power of attorney. The form includes statements about the principal being alive, the power of attorney not being revoked, and the agent's authority. It also has a place for a notary to acknowledge the agent's signature.
attorneysnotaries
The statute, as written — ‑52] 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 (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: _________________________________________________________
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