California Advance Health Care Directive Form

Only if the person making this directive is unable to write, witnesses complete this

section:

_________________________________

, being unable to write, made his/her

mark in our presence and requested the first of the undersigned to write his/her name,

which he/she did, and we now subscribe our names as witnesses thereto.

__________________________ ____________________________

Signature of Witness #1

Signature of Witness #2

NOTARY ACKNOWLEDGEMENT

(Not required if two-witness method is followed)

STATE OF CALIFORNIA, COUNTY OF _____________________________

On ___________________________, before me, ________________________________, the

undersigned notary public, personally appeared __________________________, proved to me on

the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the

within instrument and acknowledged to me that he/she/they executed the same in his/her/their

authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or

the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing

paragraph is true and correct.

WITNESS my hand and official seal.

Signature _______________________________ (Seal)

If the principal (the person appointing the agent) currently resides in

a nursing facility

, this document also must be witnessed by a representative of

California’s Long-Term Care Ombudsman Program. If the two-witness method is

chosen, the Ombudsman Program representative may serve as one of the two

witnesses, or may serve as a third witness. If the notarization method is chosen, the

Ombudsman Program representative serves as a separate witness.

4 C

 I do not currently reside in a skilled nursing facility.

_________ (initial here)

DECLARATION OF OMBUDSMAN PROGRAM REPRESENTATIVE

(Required ONLY if person appointing the agent currently resides in a nursing facility.)

I declare under penalty of perjury under the laws of California that I am an ombudsman

designated by the California Department of Aging and that I am serving as a witness as

required by Section 4675 of the California Probate Code.

_______________________________

________________________________

____________________

Name (printed)

Signature

Date

Page 4 of 4

5/12/08

California Advance Health Care Directive Form - 2008 Page 4

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