Advance Health Care Directive Form Page 5
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5ADVANCE HEALTH CARE DIRECTIVE FORM
PAGE 5 of 5
(address)
(address)
(city)
(state)
(city)
(state)
(signature of witness)
(signature of witness)
(date)
(date)
(5.4)
ADDITIONAL STATEMENT OF WITNESSES: At least one of the above witnesses must also sign the following
declaration:
I further declare under penalty of perjury under the laws of California that I am not related to the individual executing
this advance health care directive by blood, marriage, or adoption, and to the best of my knowledge, I am not entitled to any
part of the individual's estate upon his or her death under a will now existing or by operation of law.
(signature of witness)
(signature of witness)
PART 6
SPECIAL WITNESS REQUIREMENT
(6.1)
The following statement is required only if you are a patient in a skilled nursing facility--a health care facility that
provides the following basic services: skilled nursing care and supportive care to patients whose primary need is for
availability of skilled nursing care on an extended basis. The patient advocate or ombudsman must sign the following
statement:
STATEMENT OF PATIENT ADVOCATE OR OMBUDSMAN
I declare under penalty of perjury under the laws of California that I am a patient advocate or ombudsman as
designated by the State Department of Aging and that I am serving as a witness as required by Section 4675 of the Probate
Code.
(print your name)
(sign your name)
(date)
(address)
(city)
(state)
(ZIP Code)
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