Form Mtl0801-12 - Durable Power Of Attorney For Healthcare Decisions (Page 6 of 8) in pdf

Form Mtl0801-12 - Durable Power Of Attorney For Healthcare Decisions Page 6

MTL0801-12/17/2010

Division of Child and Family Services

Section 0801

Family Programs Office: Statewide Policy Manual

Subject: Youth Independent Living Program

13. (THIS POWER OF ATTORNEY WILL NOT BE VALID FOR MAKING HEALTH CARE

DECISIONS UNLESS IT IS EITHER (1) SIGNED BY AT LEAST TWO QUALIFIED

WITNESSES WHO ARE PERSONALLY KNOWN TO YOU AND WHO ARE PRESENT

WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE, OR (2)

ACKNOWLEDGED BEFORE A NOTARY PUBLIC.)

CERTIFICATE OF ACKNOWLEDGEMENT OF NOTARY PUBLIC

(You may use acknowledgement before a notary public instead of statement of witnesses.)

State of Nevada

)

: ss:

County of ______________

)

On this _____________ day of ______________________, in the year ____________,

before me, _________________________________________________ (here insert name of

notary public) personally appeared __________________________________________ (here

insert name of principal) personally known to me (or proved to me on the basis of satisfactory

evidence) to be the person whose name is subscribed to this instrument, and acknowledged that

he or she executed it. I declare under penalty of perjury that the person whose name is ascribed to

this instrument appears to be of sound mind and under no duress, fraud or undue influence.

NOTARY SEAL

__________________________________________

(Signature of Notary Public)

Date: 12/17/2010

YOUTH INDEPENDENT LIVING PROGRAM

Section 0801, Page 6 of 8

FPO 0801C - Durable Power Of Attorney

For Healthcare Decisions

Form Mtl0801-12 - Durable Power Of Attorney For Healthcare Decisions Page 6