Notarized Statutory Declaration
for Power of Attorney

Date:

Location:

Declarant Information

Full Name:

Address:

Phone:

Email:

Attorney-in-Fact Information

Full Name:

Address:

Phone:

Email:

Declaration

I, , solemnly declare that I am the above-named declarant, and I am of legal age and sound mind.

I hereby appoint as my Attorney-in-Fact, with the power and authority to act on my behalf for the following purposes:

I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath.

Declarant's Signature:

Date:

Witness / Notary:

Name:

Date:

Stamp/Seal: