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Ratification of Power of Attorney Form

STATE OF _________________
COUNTY OF ________________


_____________________, having been sworn or affirmed to tell the truth, states:

WHEREAS, on ____________, ___________________ executed a power of attorney naming myself as their attorney in fact, and,

WHEREAS, on _______________ I began to act under that power, and,

WHEREAS, ________________ is requesting verification that the power is still in force and effect,

________________________, having personal knowledge of the facts and circumstances herein, certify that the power of attorney referred to herein is still in full force and effect and that I am not aware of any event which would result in the power of attorney lapsing having taken effect.

Dated: ________________________________________



________________________________________________________


Sworn to and subscribed before me on ___________________, 199___.




_______________________________________________________
Notary Public

My Commission Expires: