Connecticut General Statutes
Chapter 15c - Connecticut Uniform Power of Attorney Act and Connecticut Uniform Recognition of Substitute Decision-Making Documents Act
Section 1-352a. - 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 THEVALIDITY OF POWER OF ATTORNEYAND AGENT'S AUTHORITY
State of ______________________________
County of ____________________________
I, _____________________ (Name of Agent), certify under penalty of false statement 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's Signature)            (Date)
 ____________________________________________
 (Agent's Name Printed)
 ____________________________________________
 ____________________________________________
 (Agent's Address)
 ____________________________________________
 (Agent's Telephone Number)
This document was acknowledged before me on _________________,                       (Date)
by ______________________________________. (Name of Agent)
________________________________________ (Seal, if any)
(Signature of Commissioner of Superior Court/Notary) My commission expires: _________________________
(P.A. 15-240, S. 42; P.A. 16-40, S. 9.)
History: P.A. 15-240 effective July 1, 2016; P.A. 16-40 changed effective date of P.A. 15-240, S. 42, from July 1, 2016, to October 1, 2016, effective May 27, 2016.

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