The Vermont Statutes Online
The Vermont Statutes Online have been updated to include the actions of the 2023 session of the General Assembly.
NOTE: The Vermont Statutes Online is an unofficial copy of the Vermont Statutes Annotated that is provided as a convenience.
Title 14 : Decedents Estates and Fiduciary Relations
Chapter 127 : Vermont Uniform Power of Attorney Act
Subchapter 003 : Statutory Forms
(Cite as: 14 V.S.A. § 4053)-
§ 4053. 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 below)
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SIGNATURE AND ACKNOWLEDGMENT
----------------- _________________________________________Agent’s Name Printed _______________________________________________________________________
Agent’s Address _______________________________________________________________________
Agent’s Telephone Number _______________________________________________________________________
This document was acknowledged before me on (Date) _________________________________________ by _______________________________________________________________________
(Name of Agent)_______________________________________________________________________Signature of Notary (Seal, if any)
My commission expires: _________________________________________
(Added 2023, No. 60, § 1, eff. July 1, 2023.)
