Durable Power Of Attorney For Health Care Template Page 8
Download a blank fillable Durable Power Of Attorney For Health Care Template in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Durable Power Of Attorney For Health Care Template with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11D
S
T
Q
W
O
N
P
ATE AND
IGNATURES OF
WO
UALIFIED
ITNESSES OR
NE
OTARY
UBLIC
Two qualified witnesses or one notary public must sign the durable power of attorney for
health care form at the same time the principal signs the document. The witnesses must be
adults and must not be any of the following:
(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, or
(5) an employee of an operator of a community care facility.
I declare under the penalty of perjury that the person who signed or acknowledged this document
is personally known to me to be the principal, that the principal signed or acknowledged this
durable power of attorney for health care 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, or an employee of an operator of
a community care facility.
OPTION ONE:
Signature:
Print Name:
Residence Address:
Date:
Signature:
Print Name:
Residence Address:
Date:
----------------------------------------------OR------------------------------------------------
OPTION TWO:
Signature of Notary Public:
Print Name:
Commission Expires:
Business Address:
Date:
6
_____ My Initials
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal