Nycers F203 Form – Fill Out and Use This PDF

NYCERS USE ONLY	F203

*203*

Affidavit That Power Of Attorney is in Full Force

This affidavit should be submitted by anyone with a Power of Attorney that was signed over one year ago. Should you have any questions regarding this affidavit, please contact our Legal Unit at (347)643-3510.

Pensioner Information

First Name	M.I.	Last Name
Address				Apt. Number
City			State		Zip Code

I, the undersigned, depose and say:

1.The Principal above did, in writing, appoint me as the Principal’s true and lawful ATTORNEY(S)-IN-FACT in the Power of Attorney dated ___________________________.

2.I have no actual knowledge or actual notice of revocation or termination of the Power of Attorney by death or otherwise, or knowledge of any facts indicating the same. I further represent that the Principal is alive, has not revoked or repudiated the Power of Attorney and the Power of Attorney still is in full force and effect.

3.I make this affidavit for the purpose of inducing NYCERS to accept delivery of this affidavit, as executed by me in my capacity as the ATTORNEY(S)-IN-FACT, with full knowledge that this affidavit will be relied upon in accepting the execution and delivery of the Power of Attorney and in paying good and valuable consideration therefor.

Signature of Power of Attorney-in-Fact

Date

Print Name

This form must be acknowledged before a Notary Public or Commissioner of Deeds

State of

County of

On this

day of

2 0

, personally appeared

before me the above named,

, to me known, and known to

me to be the individual described in and who executed the foregoing instrument, and he or she acknowledged to me that he or she

executed the same, and that the statements contained therein are true.						If you have an official seal, affix it
Signature of Notary Public or
Commissioner of Deeds
Official Title
Expiration Date of Commission

R07/27/11

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