Durable Power Of Attorney For Health Care Decisions Page 11
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12care institution or health care facility where you are receiving health
care, an employee of the health care provider who is providing health
care to you, an employee of the health care institution or health care
facility where you are receiving health care, or the person appointed as
your agent by this document; at least one of the two witnesses may not
be related to you by blood, marriage, or adoption or entitled to a portion
of your estate upon your death under your will or codicil; or
(B) acknowledged before a notary public in the state.
ALTERNATIVE NO. 1
W
W
N
R
D
P
:
ITNESS
HO IS
OT
ELATED TO OR A
EVISEE OF THE
RINCIPAL
I swear under penalty of perjury under AS 11.56.200 that the principal is
personally known to me, that the principal signed or acknowledged this durable power of
attorney for health care in my presence, that the principal appears to be of sound mind and
under no duress, fraud, or undue influence, that I am not
(1) a health care provider employed at the health care institution or health care
facility where the principal is receiving health care;
(2) an employee of the health care provider providing health care to the principal;
(3) an employee of the health care institution or health care facility where the
principal is receiving health care;
(4) the person appointed as agent by this document;
(5) related to the principal by blood, marriage, or adoption; or
(6) entitled to a portion of the principal's estate upon the principal's death under a
will or codicil.
Signature of First Witness
Date
Printed Name
Address
City
State
Zip
W
W
M
R
D
P
ITNESS
HO
AY BE
ELATED TO OR A
EVISEE OF THE
RINCIPAL
I swear under penalty of perjury under AS 11.56.200 that the principal is personally
known to me, that the principal signed or acknowledged this durable power of attorney for
health care in my presence, that the principal appears to be of sound mind and under no
duress, fraud, or undue influence, that I am not
(1) a health care provider employed at the health care institution or health care facility
where the principal is receiving health care;
(2) an employee of the health care provider who is providing health care to the principal;
11
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