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 NEW HAMPSHIRE
COUNTY OF _______________
I, _______________, certify under penalty of perjury that _______________ granted me authority as an agent in a power of attorney dated _______________.
I further certify that to my knowledge:
SIGNATURE AND ACKNOWLEDGMENT
Agent's Signature: ________________________________________
Date: __________________________________________________
Agent's Name Printed ___________________________________
Agent's Address ________________________________________
Agent's Telephone Number ______________________________
Signed and sworn to (or affirmed) before me on _______________, by _______________, known to me or satisfactorily proven to be the person named herein
Signature of Notarial Officer:
Title (and Rank):
My commission expires:
RSA 564-E:302
2017, 178 : 1 , eff. Jan. 1, 2018.