Va Advance Directive: Durable Power Of Attorney For Health Care And Living Will Page 6
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7VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
NAME (Last, First, Middle)
SOCIAL SECURITY NUMBER
PART IV: SIGNATURES
A - YOUR SIGNATURE
By my signature below, I certify that this form accurately describes my preferences.
DATE
SIGNATURE
B - WITNESSES' SIGNATURES
Two people must witness your signature. VA employees may be witnesses if they are members of:
The Chaplain Service
•
The Social Work Service
•
Nonclinical employees (e.g., Medical Administration Service, Voluntary Service, or Environmental
•
Management Service)
Other employees of your VA facility may not sign as witnesses to your advance directive unless they’re in your family.
Witness #1
I personally witnessed the signing of this advance directive. I am not appointed as Health Care Agent in this
advance directive. I am not financially responsible for the care of the person making this advance directive.
To the best of my knowledge, I am not named in the person’s will.
DATE:
SIGNATURE:
Name (Printed or Typed):
Street Address:
City, State, Zip:
Witness #2
I personally witnessed the signing of this advance directive. I am not appointed as Health Care Agent in this
advance directive. I am not financially responsible for the care of the person making this advance directive.
To the best of my knowledge, I am not named in the person's will.
SIGNATURE:
DATE:
Name (Printed or Typed):
Street Address:
City, State, Zip:
VA FORM
10-0137
Page 6 of 7
JUL 2012
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