General Information Regarding Durable Power Of (Page 3 of 3) in pdf

General Information Regarding Durable Power Of Page 3

NOTARY PUBLIC FORM

STATE OF IOWA, COUNTY OF _____________, SS:

On this_____ day of _____________, _______, before me, the undersigned, a Notary Public in and

for said state, personally appeared _____________________________________, to me known to be the

person named in and who executed the foregoing instrument and acknowledged that he/she executed the same

as his/her voluntary act and deed.

____________________________________

Notary Public in and for the State of Iowa

WITNESS FORM

We, the undersigned, hereby state that:

we signed this document in the presence of each other and the Declarant;

we witnessed the signing of the document by the Declarant or by another person acting on behalf of

the Declarant at the direction of the Declarant;

neither of us are health care providers who are presently treating the Declarant, or employees of such a

health care provider;

we are both at least 18 years of age; and

at least one of us is not related to the Declarant by blood, marriage or adoption.

________________________________________

Signature of 1st Witness

Signature of 2nd Witness

________________________________________

(Type or Print Name of Witness)

________________________________________

Street Address

________________________________________

City

State

Zip Code

City

State

Zip Code

General Information Regarding Durable Power Of Page 3