Advance Health Care Directive (Page 4 of 5) in pdf

I understand the full import of this declaration and I am emotionally and mentally competent

to make this declaration.

I execute this declaration, as my free and voluntary act

on this _________ day of ___________________________________, 20_____

_______________________________________________

[Place]

______________________________________

[Signature]

This Advance Health Care Directive will not be valid for making health care decisions unless

it is either:

o signed by two (2) qualified adult witnesses who are personally known to the

individual making the directive and who are present when the directive is signed or

acknowledged the signature on the document; or

o acknowledged before a Notary Public or Commissioner of Oaths)

I, a voluntary witness to this Advance Health Care Directive, declare under penalty of perjury

under the laws of the Republic of South Africa that:

o the individual who signed or acknowledged this Advance Health Care Directive is

personally known to me, or the individual signed or acknowledged this Advance

Directive in my presence

o the individual appears to be of sound mind and under no duress, fraud, or undue

influence

o I am not a person appointed as agent by this advance health care directive, and

o that I am not the individual’s health care provider, an employee of the individual's

health care provider, the operator of a community health care facility, the operator of

a community health care facility, the operator of a residential care facility for the

elderly, nor an employee of an operator of a residential care facility for the elderly

I further declare under the laws of penalty of perjury of the Republic of South Africa that I am

neither related to the patient by blood, marriage, or adoption, and, to the best of my

knowledge, I am not entitled to any portion of the person’s estate upon his/her death under a

will existing when the Advance Health Care Directive is executed or by operation of law.

Signed at ______________________________________

on this _______ day of __________________________, 20_____

_________________________________________________________________________

[Name and Address of First Witness]

______________________________________________

[Signature of First Witness}

_________________________________________________________________________

]

[Name and Address of Second Witness

______________________________________________

[Signature of Second Witness}

Advance Health Care Directive Page 4