AFFIDAVIT AS TO POWER OF ATTORNEY BEING IN FULL FORCE
STATE OF NEW YORK )
COUNTY OF ) ss:
, being duly sworn, deposes and says:
THAT , as principal, who resides at
, did in writing under date of ,
200 , appoint me [his/her] true and lawful attorney, and that annexed hereto, and hereby
made part hereof, is a copy of said power of attorney.
THAT, as attorney in fact of said principal and under and by virtue of the said
power of attorney, I have this day executed the following described instrum ent(s):
THAT at the time of executing the above-described instrument(s), I had no actual
knowledge or actual notice of revocation or termination of the aforesaid power of
attorney by death of said principal or otherwise, or notice of any facts indicating the
THAT I hereby represent that the said principal is now alive; has not, at any time
revoked or repudiated the said power of attorney; and the said power of attorney still is in
full force and effect.
THAT I make this affidavit for the purpose of inducing
to accept delivery of the above-described instrument(s), as executed by me in my
capacity of attorney in fact of the said principal, with the full knowledge that the above-
names parties in accepting the execution and delivery of the aforesaid instrument and in
paying a good and valuable consideration therefore, will rely upon this affidavit.
Sworn to before me this day
of , 20 .