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Agent's Certification as to the Validity of Power of Attorney (Please Print) AGENT NAME AGENT ADDRESS AGENT CITY AGENT STATE AGENT ZIP CODE PRINCIPAL NAME GREAT LAKES ID/SSN By completing this affidavit, I, the Agent, certify that to the best of my knowledge: 1. The Principal had the capacity to and did execute the Power of Attorney in which I am named Agent; 2. 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 been terminated. 3. The authority granted to me in the Power of Attorney was not fraudulently obtained; 4. I understand that the powers granted in the Power of Attorney may be revoked at any time orally or in writing; and 5. I understand that this certification is made under penalty of perjury. Agent's Signature State: ____________________ County:____________________ This document was acknowledged before me on__________________(date), by __________________________(name of Representative). Given under my hand and seal of office this___day of___________, 20___. (Personalized Seal) Notary Public's Signature Action Financial Services, LLC dba AFCS, LLC in Connecticut, Delaware, Iowa, Michigan, Texas, Washington P.O. Box 5296 Central Point, OR 97502 Fax: 541-664-4073

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Page 1: Microsoft Word - 4351A.docx - Action Financial Web viewGiven under my hand and seal of office thisday of, 20. (Personalized Seal)Notary Public's Signature. ... Microsoft Word - 4351A.docx

Agent's Certification as to the Validity of Power of Attorney

(Please Print)

AGENT NAME AGENT ADDRESS

AGENT CITY AGENT STATE AGENT ZIP CODE

PRINCIPAL NAME GREAT LAKES ID/SSN

By completing this affidavit, I, the Agent, certify that to the best of my knowledge:

1. The Principal had the capacity to and did execute the Power of Attorney in which I am named Agent;

2. 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 been terminated.

3. The authority granted to me in the Power of Attorney was not fraudulently obtained;

4. I understand that the powers granted in the Power of Attorney may be revoked at any time orally or in writing; and

5. I understand that this certification is made under penalty of perjury.

Agent's Signature

State: ________________________

County:_______________________

This document was acknowledged before me on___________________________(date), by

____________________________(name of Representative).

Given under my hand and seal of office this_______________day of______________, 20_____.

(Personalized Seal) Notary Public's Signature

Action Financial Services, LLCdba AFCS, LLC in Connecticut, Delaware, Iowa, Michigan, Texas, WashingtonP.O. Box 5296Central Point, OR 97502

Fax: 541-664-4073