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:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
(Insert other relevant statements)
SIGNATURE AND ACKNOWLEDGMENT
Agent's Signature: ________________________________________________ (Date)
Agent's Name Printed: _______________________________________
Agent's Address: ___________________________
____________________________________________
Agent's Telephone Number: __________________
This instrument was acknowledged before me on _____________________ (Date)
by ______________________________________ (Name of Agent).
Signature of notarial officer: _________________________________________
(Seal, if any)
My commission expires: ________________________.".
NMS § 45-5B-302