State Of Arizona Living Will (End Of Life Care) Page 8
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9SIGNATURE OR VERIFICATION
A. I am signing this Durable Health Care Power of Attorney as follows:
My Signature:
Date:
B. I am physically unable to sign this document, so a witness is verifying my desires as
follows:
Witness Verification: I believe that this Durable Health Care Power of Attorney
accurately expresses the wishes communicated to me by the principal of this document.
He/she intends to adopt this Durable Health Care Power of Attorney at this time. He/she
is physically unable to sign or mark this document at this time, and I verify that he/she
directly indicated to me that the Durable Health Care Power of Attorney expresses his/her
wishes and that he/she intends to adopt the Durable Health Care Power of Attorney 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 the signing of 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 form is signed.
A. Witness: I certify that I witnessed the signing of this document by the Principal. The
person who signed this Durable Health Care Power of Attorney 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 and 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:
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