Acknowledgment By Attorney in Fact

State of __________________ )
County of ________________ ) ss.
On _________________, 20___, before me, _________________________, personally
appeared _____________________________, personally known to me (or proved to me on
the basis of satisfactory evidence) to be the person whose name is subscribed to the within
instrument as the attorney in fact of ______________________________, and acknowledged
to me that he/she subscribed the name of _________________________________ thereto as
principal, and his/her own name as attorney in fact.
Subscribed and sworn to before me this
____ day of _________________, 20___.
Signature ____________________________

Example
Acknowledgment By Attorney in Fact
State of __________________ )
County of ________________ ) ss.
On _________________, 20___, before me, _________________________, personally
appeared _____________________________, personally known to me (or proved to me on
the basis of satisfactory evidence) to be the person whose name is subscribed to the within
instrument as the attorney in fact of ___(Name of person who gave power of attorney)___,
and acknowledged to me that he subscribed the name of ___(Name of person who gave
power of attorney)___ thereto as principal, and his own name as attorney in fact.
Subscribed and sworn to before me this
_____ day of _________________, 20___.
Signature ____________________________