If you don't use MS Word, you can select and copy the text below and paste into the word processor of your choice.
Agent's Certification and Acceptance of Authority Form
(Text of Section after amendment by P.A. 96‑1195)
Sec. 2‑8. Reliance on document purporting to establish an agency.
(a) Any person who acts in good faith reliance on a copy of a document purporting to establish an agency will be fully protected and released to the same extent as though the reliant had dealt directly with the named principal as a fully‑competent person. The named agent shall furnish an affidavit or Agent's Certification and Acceptance of Authority to the reliant on demand stating that the instrument relied on is a true copy of the agency and that, to the best of the named agent's knowledge, the named principal is alive and the relevant powers of the named agent have not been altered or terminated; but good faith reliance on a document purporting to establish an agency will protect the reliant without the affidavit or Agent's Certification and Acceptance of Authority.
(b) Upon request, the named agent in a power of attorney shall furnish an Agent's Certification and Acceptance of Authority to the reliant in substantially the following form:
AGENT'S CERTIFICATION AND ACCEPTANCE OF AUTHORITY
I, .......... (insert name of agent), certify that the attached is a true copy of a power of attorney naming the undersigned as agent or successor agent for ............. (insert name of principal).
I certify that to the best of my knowledge the principal had the capacity to execute the power of attorney, is alive, and has not revoked the power of attorney; that my powers as agent have not been altered or terminated; and that the power of attorney remains in full force and effect.
I accept appointment as agent under this power of attorney.
This certification and acceptance is made under penalty of perjury.*
(Print Agent's Name)
*(NOTE: Perjury is defined in Section 32‑2 of the Criminal Code of 1961, and is a Class 3 felony.)
(c) Any person dealing with an agent named in a copy of a document purporting to establish an agency may presume, in the absence of actual knowledge to the contrary, that the document purporting to establish the agency was validly executed, that the agency was validly established, that the named principal was competent at the time of execution, and that, at the time of reliance, the named principal is alive, the agency was validly established and has not terminated or been amended, the relevant powers of the named agent were properly and validly granted and have not terminated or been amended, and the acts of the named agent conform to the standards of this Act. No person relying on a copy of a document purporting to establish an agency shall be required to see to the application of any property delivered to or controlled by the named agent or to question the authority of the named agent.
(d) Each person to whom a direction by the named agent in accordance with the terms of the copy of the document purporting to establish an agency is communicated shall comply with that direction, and any person who fails to comply arbitrarily or without reasonable cause shall be subject to civil liability for any damages resulting from noncompliance. A health care provider who complies with Section 4‑7 shall not be deemed to have acted arbitrarily or without reasonable cause.
(Source: P.A. 96‑1195, eff. 7‑1‑11.)