Durable Health Care Power Of Attorney Form - Alabama Page 2
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2me, my estate, my heirs or assignees, for recognizing the agent’s authority. Although no compensation of
my agent is contemplated, (s)he shall be entitled to reimbursement of any and all reasonable expenses
incurred as a result of carrying out any provision of this document.
Invalidity of one or more powers shall not invalidate any others.
I am in full control of my mental faculties and I understand the contents of this document and the effect of
this grant of powers to my agent.
Dated this _____ day of ______________, 201__.
_________________________
,Grantor
WITNESSES
I believe the Grantor to be of sound mind and able to make decisions of this kind. I did not sign his/her
name and I am not the health care agent. I am not related to the Grantor by blood, adoption or marriage,
and not entitled to any part of his/her estate. I am at least 19 years old and am not directly responsible for
his/her medical care or expenses.
_________________________
Signature of Witness
_________________________
Name of Witness
Date: _____________
and
________________________
Signature of Witness
_________________________
Name of Witness
Date: _____________
ATTESTATION
I, the undersigned authority in and for said County in said State, hereby certify that __________________,
whose name is signed to the foregoing Durable Health Care Power of Attorney, and who is known to me,
acknowledged before me on this day that, being informed of the contents of the said document, (s)he
executed the same voluntarily, before the witnesses whose names appear above, on the day the same bears
date.
Given under my hand this _________ day of _____________, 2002.
__________________________
Notary Public
My commission expires:
_____________________
SIGNATURES OF AGENTS
I, ____________________, am willing to serve as Health Care Agent.
Signature: ______________________ Date: ______________
I, _____________________, am willing to serve as Health Care Agent if the first-named Agent cannot
serve.
Signature: ____________________ Date: _______________
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