State Of Arizona Living Will (End Of Life Care) Page 3
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9GNATURE OR VERIFICATION
A. I am signing this Living Will as follows:
My Signature:
Date:
B. I am physically unable to sign this Living Will, so a witness is verifying my desires as
follows:
Witness Verification: I believe that this Living Will accurately expresses the wishes
communicated to me by the principal of this document. He/she intends to adopt this
Living Will at this time. He/she is physically unable to sign or mark this document at this
time. I verify that he/she directly indicated to me that the Living Will expresses his/her
wishes and that he/she intends to adopt the Living Will at this time.
Witness Name (printed):
Signature:
Date:
SIGNATURE OF WITNESS OR NOTARY PUBLIC
NOTE: At least one adult witness OR a Notary Public must witness you signing this
document and then sign it. The witness or Notary Public CANNOT be anyone who is: (a)
under the age of 18; (b) related to you by blood, adoption, or marriage; (c) entitled to any
part of your estate; (d) appointed as your representative; or (e) involved in providing your
health care at the time this document is signed.
A. Witness: I certify that I witnessed the signing of this document by the Principal. The
person who signed this Living Will appeared to be of sound mind and under no pressure
to make specific choices or sign the document. I understand the requirements of being a
witness. I confirm the following:
• I am not currently designated to make medical decisions for this person.
• I am not directly involved in administering health care to this person.
• I am not entitled to any portion of this person’s estate upon his or her death under
a will or by operation of law.
• I am not related to this person by blood, marriage, or adoption.
Witness Name (printed):
Signature:
Date:
Address:
B. Notary Public: (NOTE: a Notary Public is only required if no witness signed above)
STATE OF ARIZONA
ss
COUNTY OF
)
The undersigned, being a Notary Public certified in Arizona, declares that the person
making this Living Will has dated and signed or marked it in my presence, and appears to
me to be of sound mind and free from duress. I further declare I am not related to the
person signing above, by blood, marriage or adoption, or a person designated to make
medical decisions on his/her behalf. I am not directly involved in providing health care to
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