                                 CODE OF VIRGINIA

AGENT&#8217;S CERTIFICATION (§ 64.2-1639)

The following optional form may be used by an agent to certify facts concerning
a power of attorney.
		AGENT&#8217;S CERTIFICATION AS TO THE VALIDITY OF POWER OF ATTORNEY AND
AGENT&#8217;S AUTHORITY
		State of ____________________
		County/City 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&#8217;s Signature
			____________________Date
			Agent&#8217;s Name Printed________________________________________
			________________________________________ Agent&#8217;s Address
			________________________________________Agent&#8217;s Telephone Number
			This document was acknowledged before me on ____________________ (Date), by
____________________ (Name of Agent).________________________________________
Signature of Notary
			My commission expires: ____________________ (Seal, if any)
			Notary Registration Number: ____________________
			This document prepared by:
			________________________________________

HISTORY: 2010, cc. 455, 632, § 26-113; 2012, c. 614.