Arkansas Durable Power Of Attorney For Health Care Template Page 2
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1
2If
resigns, or is not able or available
to make health care decisions for me, or if an agent named by me is
divorced from me or is my spouse and legally separated from me, I
appoint
as successor, with all of the rights
and powers and authority herein stated. The term “health care” shall
have the meaning set forth in Ark. Code Ann. § 20-13-104(c). This
Durable Power of Attorney for Health Care shall not be affected by my
subsequent disability or incapacity.
Optional Instructions:
If the health care agent I appoint is unable, unwilling or
unavailable to act as my health care agent, then I appoint:
(Name, home address and telephone number of alternate agent)
as my
alternate health care agent.
Signed this
day of
,
.
(Day)
(Month)
(Year)
Signature
Address
Statement by Witnesses (must be 18 or older):
I declare that the person who signed this document appeared to
execute the durable power of attorney for health care willingly and free
from duress. He or she signed (or asked another to sign for him or her)
this document in my presence.
1) Witness
(Sign and Print name)
Address
2) Witness
(Sign and Print name)
Address
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