Idaho Durable Power Of Attorney For Health Care Template (Page 2 of 2) in pdf

Idaho Durable Power Of Attorney For Health Care Template Page 2

10. Signature - I sign my name to this Statutory Form Durable Power of Attorney for Health Care on the _____

day of __________________ in the year _______ , at _______________________ , ______________ .

______________________

(signature)

(You must choose to have this Durable Power of Attorney for Health Care notarized or witnessed by two people who

know you well, but aren't related to you and aren't potential heirs or your health care providers)

(Witness Option)

STATEMENT OF WITNESSES

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

document is personally known to me (or proved to me on the basis of convincing evidence) to be the principal, that the

principal signed or acknowledged this 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 health care provider, an employee of a health care provider, the operator of a

community care facility, nor an employee of an operator of a community care facility.

I further declare under penalty of perjury under the laws of the State of Idaho that I am not related to the

principal by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the estate of

the principal upon the death of the principal under a will now existing or by operation of law.

WITNESS A

WITNESS B

Signature/Date:

Print Name:

Address:

(Notary Option)

STATE OF IDAHO

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: ss

County of _________

}

On this _______ day of _____________________ , in the year ________ , before me personally appeared

_________________________________ , to me known (or proved to me on basis of satisfactory evidence) to be the

person whose name is subscribed to this instrument, as the principal and acknowledged that he/she executed it. I

declare under penalty of perjury that the person whose name is subscribed to this instrument appears to be of sound

mind and under no duress, fraud or undue influence.

_____________________________

Notary Public for the State of Idaho

My Commission Expires:

Idaho Durable Power Of Attorney For Health Care Template Page 2