(NOTE: This form does not authorize your agent to appear in court for you as an
attorney-at-law or otherwise to engage in the practice of law unless he or she is a licensed
attorney who is authorized to practice law in Illinois.)
11. The Notice to Agent is incorporated by reference and included as part of this form.
Dated: ................
Signed ...........................................
(principal)
(NOTE: This power of attorney will not be effective unless it is signed by at least one witness
and your signature is notarized, using the form below. The notary may not also sign as a
witness.)
The undersigned witness certifies that ..............., known to me to be the same person whose
name is subscribed as principal to the foregoing power of attorney, appeared before me and
the notary public and acknowledged signing and delivering the instrument as the free and
voluntary act of the principal, for the uses and purposes therein set forth. I believe him or her
to be of sound mind and memory. The undersigned witness also certifies that the witness is
not: (a) the attending physician or mental health service provider or a relative of the
physician or provider; (b) an owner, operator, or relative of an owner or operator of a health
care facility in which the principal is a patient or resident; (c) a parent, sibling, descendant, or
any spouse of such parent, sibling, or descendant of either the principal or any agent or
successor agent under the foregoing power of attorney, whether such relationship is by
blood, marriage, or adoption; or (d) an agent or successor agent under the foregoing power
of attorney.
Dated: ................
..............................
Witness
(NOTE: Illinois requires only one witness, but other jurisdictions may require more than one
witness. If you wish to have a second witness, have him or her certify and sign here:)
(Second witness) The undersigned witness certifies that ................, known to me to be the
same person whose name is subscribed as principal to the foregoing power of attorney,
appeared before me and the notary public and acknowledged signing and delivering the
instrument as the free and voluntary act of the principal, for the uses and purposes therein
set forth. I believe him or her to be of sound mind and memory. The undersigned witness
also certifies that the witness is not: (a) the attending physician or mental health service
provider or a relative of the physician or provider; (b) an owner, operator, or relative of an
1
2
3
4
5
6
7
8
9
