Durable Power Of Attorney For Health Care (Page 10 of 15) in pdf

Durable Power Of Attorney For Health Care Page 10

IV. Signature of Principal

I have discussed this designation with my above-named patient advocate who intends to sign the attached

acceptance to this designation (check one):

□

Concurrently with the execution of this document.

□

At a future date.

I freely and voluntarily sign this document, in the presence of the below-named witnesses, and it shall

become effective on the date indicated below.

Your signature)

(Date)

(Print or type full name)

(Address)

(City)

(State)

(Zip)

ATTESTATION OF WITNESSES

As a witness to the execution of this durable power of attorney, I attest that the person who has signed this

document in my presence appears to be of sound mind and under no duress, fraud, or undue influence, I

further attest that I am not the person’s spouse, parent, child, grandchild, sibling, presumptive heir, know

devisee at the time of this witnessing, physician, the named patient advocate, an employee of a life or

health insurance provider for the person, or an employee of a health facility that is treating the person or a

home for the aged where the person resides.

First Witness’s Signature

Address

Type or Print Name

City

State

Zip

Second Witness’s Signature

Address

Type or Print Name

City

State

Zip

Durable Power Of Attorney For Health Care Page 10