Idaho Durable Power Of Attorney For Health Care Page 4
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5______________ (date) at ________________ (city), ______________ (state).
__________________________________
(You sign here)
(This Power of Attorney will not be valid unless it is signed by two qualified witnesses
who are present when you sign or acknowledge your signature. If you have attached any
additional pages to this form, you must date and sign each of the additional pages at the
same time you date and sign this Power of Attorney.)
STATEMENT OF WITNESSES
(This document must be witnessed by two qualified adult witnesses. None of the
following may be used as a witness: (1) a person you designate as your agent or alternate
agent, (2) a health care provider, (3) an employee of a health care provider, (4) the
operator of a community care facility, (5) an employee of an operator of a community
care facility. At least one of the witnesses must make the additional declaration set out
following the place where the witnesses sign.)
I declare under penalty of perjury under the laws of Idaho that the person who signed
or acknowledged this document is personally known to me (or proved to me on the basis
of convincing evidence) to be the principal, that the principal signed or acknowledged
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, and that I am not a health care provider, an
employee of a health care provider, the operator of a community care facility, nor an
employee of an operator of a community care facility.
Signature: ____________________
Print name: _________________________
Date: ____________ Residence address: ________________________
Signature: ____________________
Print name: _________________________
Date: ____________ Residence address: ________________________
(At least one of the above witnesses must also sign)
I further declare under penalty of perjury under the laws of Idaho that I am not related
to the principal by blood, marriage, or adoption, and, 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 now existing or by operation of law.
Signature: ...................................................................
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