Medical Power Of Attorney Form (Page 2 of 2) in pdf

Medical Power of Attorney (pg 2)

Statement of Witnesses

I hereby declare under penalty of perjury that the person who signed or acknowledged this document is personally

known to me (or proved to me on the basis of convincing evidence) to be the principal, that the principal signed or

acknowledged this durable medical power of attorney in my presence, that the principal appears to be of sound mind

and under no duress, fraud, or undue influence. I am not the person appointed an agent by this document. I am not

related to the principal by blood, marriage, or adoption. I would not be entitled to any portion of the principal's estate

on the principal's death. I am not the attending physician of the principal or an employee of the attending physician. I

have no claim against any portion of the principal's estate on the principal's death. Furthermore, if I am an employee

of a health care facility in which the principal is a patient, I am not involved in providing direct patient care to the

principal and am not an officer, director, partner, or business office employee of the health care facility or of any

parent organization of the health care facility.

_____________________________________

______________________

Witness

Date

_____________________________________

______________________

Witness

Date

Subscribed and sworn to before me on [DATE]__________________________.

______________________________________________________________________________________

Notary Public, [COUNTY, STATE]

My commission expires ______________.

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Medical Power Of Attorney Form Page 2