                                 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.