Mississippi Power Of Attorney For Health Care Template Page 8
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8ALTERNATIVE NO. 2
State of __________
County of __________
On this ________ day of ________, in the year ________, before me,
___________________________ appeared ___________________________
personally known to me (or proved to me on the basis of satisfactory evidence) to
be the person whose name is subscribed to this instrument, and acknowledged
that he or she executed it. I declare under the penalty of perjury that the person
whose name is subscribed to this instrument appears to be of sound mind and
under no duress, fraud or undue influence.
Notary Seal
____________________________
(Signature of Notary Public)
My commission expires: __________________
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