Durable Health Care Power Of Attorney Instructions And Form (Page 4 of 12) in pdf

DURABLE HEALTH CARE POWER OF ATTORNEY (Cont’d)

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: _________________________________________________________________________________

Notary Public (NOTE: If a witness signs your form, you DO NOT need a notary to sign):

STATE OF ARIZONA

) ss

COUNTY OF

____________________)

The undersigned, being a Notary Public certified in Arizona, declares that the person making this

Durable Health Care Power of Attorney 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 the person signing. I am not entitled to any

part of his/her estate under a will now existing or by operation of law. In the event the person

acknowledging this Durable Health Care Power of Attorney is physically unable to sign or mark this

document, I verify that he/she directly indicated to me that this 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 MY HAND AND SEAL this ___ day of ______________, 20___.

Notary Public _____________________________________ My Commission Expires: __________________

OPTIONAL:

STATEMENT THAT YOU HAVE DISCUSSED

YOUR HEALTH CARE CHOICES FOR THE FUTURE

WITH YOUR PHYSICIAN

NOTE: Before deciding what health care you want for yourself, you may wish to ask your physician questions

regarding treatment alternatives. This statement from your physician is not required by Arizona law. If you do

speak with your physician, it is a good idea to have him or her complete this section. Ask your doctor to keep a

copy of this form with your medical records.

_______________________________________________________________________________________________________________

Developed by the Office of Arizona Attorney General

Updated January 18, 2011

TOM HORNE

(All documents completed before January 18, 2011 are still valid)

DURABLE HEALTH CARE POWER OF ATTORNEY

Durable Health Care Power Of Attorney Instructions And Form Page 4

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