Okla. Stat. tit. 58, § 58-3042: 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)

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 Notary: _______________________________________________

My commission expires: _______________

This document prepared by: _________________________________________