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

Form Mtl0801-12 - Durable Power Of Attorney For Healthcare Decisions Page 8

MTL0801-12/17/2010

Division of Child and Family Services

Section 0801

Family Programs Office: Statewide Policy Manual

Subject: Youth Independent Living Program

I declare under penalty of perjury 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 by operation of law.

Witness #1:

Signature: __________________________________________________________________

Print Name: _________________________________________________________________

Residence Address: __________________________________________________________

_____________________________________________________________

Date: ______________________________________________________________________

Witness #2:

Signature: __________________________________________________________________

Print Name: _________________________________________________________________

Residence Address: __________________________________________________________

_____________________________________________________________

Date: _____________________________________________________________________

COPIES: You should retain an executed copy of this document and give one to your

agent. The Power of Attorney should be available so a copy may be given to your

providers of health care.

Date: 12/17/2010

YOUTH INDEPENDENT LIVING PROGRAM

Section 0801, Page 8 of 8

FPO 0801C - Durable Power Of Attorney

For Healthcare Decisions

Form Mtl0801-12 - Durable Power Of Attorney For Healthcare Decisions Page 8