Affidavit By Attorney-In-Fact

STATE OF ----------)

) s.s.:

COUNTY OF ---------)

[Name in capital letters] (Affiant), being duly sworn, says:

1. I reside at [address, city, state of Affiant].

2. I am Attorney-in-Fact for [name of principal] under power of attorney executed by

[principal], dated [date]. As of the date of this Affidavit, [principal] is alive and well, and has
agreed to the terms of [description of contract, e.g., sale of land, goods].

3. This Affidavit is made for the purpose of inducing [name] to [description of purpose, e.g.,
to induce a party to accept a conveyance, a bank to provide a loan].

[signature]

Attorney-in-Fact

Sworn to before me this [dated].

[signature]

Notary Public