Va Advance Directive: Durable Power Of Attorney For Health Care And Living Will Page 7
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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 V: SIGNATURE AND SEAL OF NOTARY PUBLIC (Optional)
This VA Advance Directive form is valid in VA facilities without being notarized. However, you may need to
have it notarized to be legally binding outside the VA health care setting. Space for a Notary's signature and
seal is included below.
On this
day of
, in the year of
, personally appeared before
,
me
known by me to be the person who completed this document and acknowledged it as their free act
and deed. IN WITNESS WHEREOF, I have set my hand and affixed my official seal in the County
, on the date written above.
, State of
of
Notary Public
Commission Expires
[SEAL]
From
VA FORM
10-0137
Page 7 of 7
JUL 2012
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