Living Will Form Page 9
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(NOTE: This Form is Optional)
WITNESSES' AFFIDAVITS
STATE OF CONNECTICUT
)
:
ss. __________________________
COUNTY OF ____________________________
)
(Town)
We, the subscribing witnesses, being duly sworn, say that we witnessed the execution of these health care instructions, the
appointments of a health care agent and an attorney-in-fact, the designation of a conservator for future incapacity and a
document of anatomical gift by the author of this document; that the author subscribed, published and declared the same to be
the author's instructions, appointments and designation in our presence; that we thereafter subscribed the document as
witnesses in the author's presence, at the author's request and in the presence of each other; that at the time of the execution of
said document the author appeared to us to be eighteen years of age or older, of sound mind, able to understand the nature
and consequences of said document, and under no improper influence, and we make this affidavit at the author's request this
_____ day of ______________________, 200____.
x_____________________________
x____________________________
(Witness)
(Witness)
x_____________________________
x____________________________
(Number and Street)
(Number and Street)
x_____________________________
x____________________________
(City, State and Zip Code)
(City, State and Zip Code)
Personally appeared ____________________________, signer of the foregoing instrument, and acknowledged the same to
be his/her free act and deed, before me, this ______ day of _________________________, 200____.
__________________________________
Commissioner of the Superior Court
Notary Public
My Commission expires: _____________
(Print or type name of all persons signing under all signatures)
THIS IS A SAMPLE AND OFFERED SOLELY FOR THE ASSISTANCE OF ATTORNEYS WHO WILL BE RESPONSIBLE FOR THE
ULTIMATE SUBSTANCE AND WORDING OF THE DOCUMENT. THE USE OF THIS SAMPLE BY PARTIES OTHER THAN ATTORNEYS
IS NOT AUTHORIZED
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