Health Care Power Of Attorney (Page 6 of 6) in pdf

Health Care Power Of Attorney Page 6

this date without a will. I also state that I am not the principal's attending physician, nor a licensed health care

provider or mental health treatment provider who is (1) an employee of the principal's attending physician or mental

health treatment provider, (2) an employee of the health facility in which the principal is a patient, or (3) an

employee of a nursing home or any adult care home where the principal resides. I further state that I do not have any

claim against the principal or the estate of the principal.

Date: _____________________________ Witness: __________________________________________________

________________COUNTY, _________________STATE

Sworn to (or affirmed) and subscribed before me this day by _____________Bob Bobcat_____________________

(type/print name of signer)

_____________________________________________

(type/print name of witness)

_____________________________________________

(type/print name of witness)

Date: ___________________________

_____________________________________________________

(Official Seal)

Signature of Notary Public

_________________________________________, Notary Public

Printed or typed name

My commission expires: _________________________________

Health Care Power Of Attorney Page 6