Durable Power Of Attorney For Property/illinois Statutory Short Form Power Of Attorney For Property Page 7

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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
State of ............)
) SS.
County of ...........)
The undersigned, a notary public in and for the above county and state, 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 witness(es) ............. (and
..............) in person and acknowledged signing and delivering the instrument as the free and
voluntary act of the principal, for the uses and purposes therein set forth (, and certified to the
correctness of the signature(s) of the agent(s)).
Dated: ................
..............................
Notary Public
My commission expires .................
(NOTE: You may, but are not required to, request your agent and successor agents to
provide specimen signatures below. If you include specimen signatures in this power of
attorney, you must complete the certification opposite the signatures of the agents.)
Specimen signatures of
I certify that the signatures
agent (and successors)
of my agent (and successors)
are genuine.
..........................
.............................
(agent)
(principal)
..........................
.............................

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