Durable Power Of Attorney For Healthcare Decisions Page 6

ADVERTISEMENT

STATEMENT OF WITNESSES
(You should carefully read and follow this witnessing procedure. This document will not
be valid unless you comply with the witnessing procedure. If you elect to use witnesses
instead of having this document notarized, you must use two qualified adult witnesses.
None of the following may be used as a witness: (1) a person you designate as the
attorney-in-fact; (2) a provider of health care; (3) an employee of a provider of health
care; (4) the operator of a health care facility; (5) an employee of an operator of a
healthcare facility. At least one of the witnesses must make the additional declaration set
out following the place where the witnesses sign.)
I declare under penalty that the principal is personally known to me, that the principal signed
or acknowledged the Durable Power of Attorney in my presence, that the principal appears to
be of sound mind and under no duress, fraud, or undue influence, that I am not the person
appointed as attorney-in-fact by this document, and that I am not a provider of health care, an
employee of a provider of health care, the operator of a community care facility, nor an
employee of an operator of health care facility.
Witness #1:
Signature: __________________________________________________________________
Print Name: _________________________________________________________________
Residence Address: __________________________________________________________
__________________________________________________________
Date: ______________________________________________________________________
Witness #2:
Signature: __________________________________________________________________
Print Name: ________________________________________________________________
Residence Address: __________________________________________________________
__________________________________________________________
Date: ______________________________________________________________________
(AT LEAST ONE OF THE ABOVE WITNESSES MUST ALSO SIGN THE FOLLOWING
DECLARATION.)
6

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 8