Mississippi Power Of Attorney For Health Care Template Page 7
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8ALTERNATIVE NO. 1
Witness
I declare under penalty of perjury pursuant to Section 97-9-61, Mississippi Code of
1972, that the principal is personally known to me, that the principal signed or
acknowledged this power of attorney in my presence, that the principal appears to be of
sound mind and under no duress, fraud or undue influence, that I am not the person
appointed as agent by this document, and that I am not a health-care provider, nor an
employee of a health-care provider or facility. 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 or by
operation of law.
___________________________
____________________________
(date)
(signature of witness)
_________________________________________
_________________________________________
(address)
(printed name of witness)
_________________________________________
(city)
(state)
Witness
I declare under penalty of perjury pursuant to Section 97-9-61, Mississippi Code of
1972, that the principal is personally known to me, that the principal signed or
acknowledged this power of attorney in my presence, that the principal appears to be of
sound mind and under no duress, fraud or undue influence, that I am not the person
appointed as agent by this document, and that I am not a health-care provider, nor an
employee of a health-care provider or facility.
________________________________
___________________________
(date)
(signature of witness)
___________________________________________
____________________________________
(address)
(printed name of witness)
___________________________________________
(city)
(state)
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