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