Health Powers Of Attorney Form For Indiana Residents (Page 2 of 2) in pdf

Health Powers Of Attorney Form For Indiana Residents Page 2

CHECK ONE OF THE FOLLOWING BOXES:

This power of attorney shall terminate upon my disability, incapacity or incompetence.

This power of attorney is effective immediately, and shall not be affected by my disability, incapacity or

incompetence.

This power of attorney will become effective upon my disability, incapacity or incompetence.

I understand that in accordance with Indiana Code 30-5-10-1, except as otherwise stated in this power of attorney

form, this executed power of attorney may be revoked only in writing wherein the written revocation statement

identifies the power of attorney revoked and is signed by myself, the principal. This power of attorney shall continue

in full force and effect until I have executed and recorded in the Recorder’s Office of the county of my domicile a

written revocation hereof.

Signed this ________ day of _______________, _________.

____________________________________

_____________________________

(Your signature)

(Your social security number)

State of __________________.

County of ________________.

On this _____________day of ______________________, ________, before me personally appeared

______________________________________ (name of principal), who is personally known to me or provided

______________________________________________as identification, and acknowledged that he or she

executed this health powers of attorney form.

____________________________

Notary Public

Health Powers of Attorney Form: Created 1/15/09

Page 2 of 2

Health Powers Of Attorney Form For Indiana Residents Page 2