Durable Health Care Power Of Attorney (Page 4 of 5) in pdf

Witness Name (printed): ________________________________________________________________

Signature: ______________________________________________ Date: ________________________

SIGNATURE OF WITNESS OR NOTARY PUBLIC:

NOTE: At least one adult witness OR a Notary Public must witness the signing of this document and then

sign it. The witness or Notary Public CANNOT be anyone who is: (a) under the age of 18; (b) related to

you by blood, adoption, or marriage; (c) entitled to any part of your estate; (d) appointed as your

representative; or (e) involved in providing your health care at the time this form is signed.

A. Witness: I certify that I witnessed the signing of this document by the Principal. The person who

signed this Durable Health Care Power of Attorney appeared to be of sound mind and under no

pressure to make specific choices or sign the document. I understand the requirements of being a

witness and I confirm the following:

 I am not currently designated to make medical decisions for this person.

 I am not directly involved in administering health care to this person.

 I am not entitled to any portion of this person's estate upon his or her death under a will or by

operation of law.

 I am not related to this person by blood, marriage or adoption.

Witness Name (printed): ________________________________________________________________

Signature: ________________________________________________ Date: ______________________

Address: ____________________________________________________________________________

Notary Public (NOTE: If a witness signs your form, you DO NOT need a notary to sign):

STATE OF ARIZONA

) ss

COUNTY OF ______________________)

The undersigned, being a Notary Public certified in Arizona, declares that the person making this

Durable Health Care Power of Attorney has dated and signed or marked it in my presence and

appears to me to be of sound mind and free from duress. I further declare I am not related to the

person signing above by blood, marriage or adoption, or a person designated to make medical

decisions on his/her behalf. I am not directly involved in providing health care to the person

signing. I am not entitled to any part of his/her estate under a will now existing or by operation of

law. In the event the person acknowledging this Durable Health Care Power of Attorney is

physically unable to sign or mark this document, I verify that he/she directly indicated to me that

this Durable Health Care Power of Attorney expresses his/her wishes and that he/she intends to

adopt the Durable Health Care Power of Attorney at this time.

WITNESS MY HAND AND SEAL this _____ day of _________________, 20_____.

Notary Public ____________________________________ My Commission Expires: _______________

America Living Will Registry, LLC, 2814 Beach Boulevard South, St. Petersburg, FL 33707

1-866-305-ALWR

web site:

e-mail:

Durable Health Care Power Of Attorney Page 4