Affidavit Of Physician printable pdf download

Affidavit Of Physician

AFFIDAVIT OF PHYSICIAN

State of FLORIDA

County of _______________

Before me, the undersigned authority, personally appeared ________________________________,

name of physician

Affiant, who swore or affirmed that:

1. Affiant is a physician licensed to practice medicine in:

________________________________________________________________________.

name of state, territory, or foreign country

2. Affiant is the primary physician who has responsibility for the treatment and care of:

_______________________________________________________________________.

principal’s name

3. To the best of the Affiant's knowledge after reasonable inquiry, Affiant believes that the

principal lacks the capacity to manage property, including taking actions necessary to

obtain, administer, and dispose of real and personal property, intangible property, business

property, benefits, and income.

___________________________________

affiant signature

___________________________________

affiant printed name

Sworn to (or affirmed) and subscribed before me this _____ day of _____________ 20_____ by

__________________________________ who q is personally known to me or q produced a

_______________________________ as identification.

(SEAL)

___________________________

notary public signature

___________________________

notary public printed name

FL-2191-AFF

provides this form pursuant to Florida Statute §709.08(4)(d)

Affidavit Of Physician