Indiana - Rest Of Your Life Page 4

APPOINTER SIGNATURE

, the Appointer, sign my name to this instrument this

day of

(day)

_, and do hereby declare the undersigned witness that I sign it

(month)

(year)

willingly, and I execute it as my free and voluntary act for the purposes herein expressed, and that I am eighteen (18) years

of age or older, of sound mind, and under no constraint or undue influence.

(Signature)

(Date)

(Printed Name)

(Address)

(County)

(City/State/Zip)

WITNESS SIGNATURE

I declare that the Appointer who signed this document appears to be of sound mind and acting of his/her own free will.

He/She signed (or asked another to sign for him/her) this document in my presence.

I further declare that I am an adult at least eighteen (18) years of age, and I am not the Representative or Successor

Representative appointed in this document.

(Signature of Witness)

(Printed Name)

(Witness Address)

(City/State/Zip)

(Telephone Number)

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