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By signing this form I cerify, under penalty of perjury, that this informaion contained herein is correct. I understand that pursuant to the.This form must be notarized on or after the date of the Attorney-in-Fact's signature. Affiant is the attorney in fact named in the Durable Power of Attorney executed by. Instructions: Please complete both pages of this form. Each Attorney-in-Fact added to an account must complete and submit a separate form. Healthcare and the Power of Attorney; Affidavit of Attorney-in-Fact. (NOTE: Not all of this information may apply to you personally. Able to process incomplete forms. When signed, this document transfers the ability to represent the principal in decision making to the attorneyinfact.