Durable Power Of Attorney For Health Care Page 2
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1
2I want this person to have my power of attorney to do the things described on the first page:
:
Person to have Power of Attorney for Health Care
(Attorney in Fact)
Name: _________________________________________________________
Street Address: _________________________________________________
City: ____________________ State: ________ Phone: _________________
If the person named above is unable or unwilling to serve, I appoint the following person as my
successor (backup) attorney in fact with full powers and responsibilities to make health care
decisions on my behalf.
Backup Person to have Power of Attorney for Health Care
:
(Successor Attorney in Fact)
Name: _________________________________________________________
Street Address: _________________________________________________
City: ____________________ State: ________ Phone: _________________
I authorize the use of copies of this document.
I hereby execute this Durable Power of Attorney For Health Care on the _____ day of
_______________, 20__.
My signature: ____________________________________
Person giving the Power of Attorney for Health Care (Principal)
Declaration of Witnesses
Each of the undersigned witnesses makes the following declaration: “I declare under penalty of
perjury under the laws of Tennessee that the person who signed this document is personally known to
me to be the principal; that the principal signed this durable power of attorney in my presence; that the
principal appears to be of sound mind and under no duress, fraud or undue influence; that I am not the
person appointed as attorney in fact by this document; that I am not a health care provider, an employee
of a health care provider, the operator of a health care institution nor an employee of an operator of a
health care institution; that I am not related to the principal by blood, marriage, or adoption; that, to
the best of my knowledge, I do not, at the present time, have a claim against any portion of the estate
of the principal upon the death of the principal; and, that, to the best of my knowledge, I am not entitled
to any part of the estate of the principal upon the death of the principal under a will or codicil thereto
now existing, or by operation of law.”
__________________________________________
____________________________________________
Signature of Witness
Signature of Witness
Date: ______________
Date: ______________
STATE OF TENNESSEE
COUNTY OF _______________________
Subscribed, sworn to and acknowledged before me by ____________________________________, the
principal, and subscribed and sworn to before me by ____________________________________ and
____________________________________, witnesses, this _____ day of ______________, 20___.
____________
_______________________________
My commission expires: ________________
Notary Public
8/98 - Legal Aid Society of Middle Tennessee
Durable Power Of Attorney For Health Care - page 2 of 2
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