Fillable Statutory Advance Directive (Page 8 of 8) in pdf

Statutory Advance Directive Page 8

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understand its purpose, effect, consequences, and full import. Further, I am of legal age, and I

am emotionally and mentally competent to complete this document. I am acting voluntarily and

without fraud, duress or undue influence.

(Do not sign until in the presence of a notary, below)

29.

Signed:__________________________________ Date: ______________________

At: (City) _______________________________

(State) _____________________

CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC:

30. State of Indiana,

}

County of_______________________

Place: __________________________

On this______day of _____________________________, in the year_______, before me

(insert

: _________________________________, personally appeared

officer name/title)

(insert name of

:_______________________________, personally known to me (or proved to

Principal on line here)

me on the basis of satisfactory evidence (

______________________

) to be the person(s)

describe:

)

whose name(s) is/are subscribed to this/these instrument(s) and acknowledged to me that he/she

executed the same in his/her authorized capacity, and that by his/her signature on the

instrument(s), executed the instrument(s). I declare that he/she appears of sound mind and not

under or subject to duress, fraud, or undue influence, that he/she acknowledges the execution of

the same to be his/her voluntary act and deed, and that I am not the agent (attorney-in-fact),

proxy, surrogate, or a successor of any such, as designated within this document, nor do I hold

any interest in his/her estate through a Will or by other operation of law.

WITNESS my hand and official seal.

___________________________________

Notary Seal:

Signature of Notary Public

___________________________________

Date Commission Expires

Statutory Advance Directive Page 8

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