Health-Care Power Of Attorney Form Page 4
Download a blank fillable Health-Care Power Of Attorney Form 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 Health-Care Power Of Attorney Form 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
4Nebraska State Unit on Aging
Surrogate Decision Making in Nebraska
Declaration of Witnesses
We declare that the principal is personally known to us, that the principal signed or acknowledged
his or her signature on this power of attorney for health care in our presence, and that the principal
appears to be of sound mind and not under duress or undue influence, and that neither of us nor the
principal’s attending physician is the person appointed as attorney in fact by this document.
Witnessed By:
________________________________________ ________________________________________
(Signature of Witness/Date)
(Printed Name of Witness)
________________________________________ ________________________________________
(Signature of Witness/Date)
(Printed Name of Witness)
OR
State of Nebraska
)
) ss,
County of ______________________________
)
On this _______ day of ______________________ 20 ____, before me, _________________
a notary public in and for ______________________________________ County, personally came
_______________________________, personally known to be the identical person whose name
is affixed to the above power of attorney for health care as principal, and I declare that he or she
acknowledges the execution of the same to be his or her voluntary act and deed, and that I am not the
attorney-in-fact or successor attorney-in-fact designated by this power of attorney for health care.
Witness my hand and notarial seal at _______________________ in such county the day and
year last above written.
___________________________________________
Notary Public
29
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal