Protective Durable Power Of Attorney For Health Care (Page 8 of 8) in pdf

Protective Durable Power Of Attorney For Health Care Page 8

WITNESSES

I am at least 18 years of age. I am not the person appointed as an agent in this document.

I declare under penalty of perjury that the person who signed or acknowledged this

durable power of attorney for health care is personally known to me and I believe he/she

is of sound mind and at least 18 years of age or an emancipated minor. He/she signed or

acknowledged this document in my presence and did not appear to be under duress or

undue influence.

I am not the signer’s health care provider, the owner or operator of the health care facility

(including the hospital or long-term care or other residential or community care facility) which

is serving the signer, or an employee or agent of the signer’s health care provider or facility.

I am not financially responsible for the signer’s care nor am I an employee or agent of his/her

life insurance or health insurance provider.

I am not related to the signer by blood, marriage, or adoption. To the best of my knowledge, I

am not entitled to and do not have a claim on his/her estate.

Witness No. 1:

(print) Name_______________________________________Date__________________

(print) Address___________________________________________________________

Signature__________________________________________________________

Witness No. 2:

(print) Name________________________________________Date_________________

(print) Address___________________________________________________________

Signature__________________________________________________________

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Protective Durable Power Of Attorney For Health Care Page 8