Kentucky Health Care Power Of Attorney Form Page 3
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3IN TESTIMONY WHEREOF, witness my signature this _____ day of ___________ (month), ______(year).
_______________________________________
_______________________________________
Principle Signature
Witness
_______________________________________
Address
COMMONWEALTH OF KENTUCKY )
)
________________________________________
COUNTY OF __________________ )
Witness
________________________________________
Address
OR
Before me, a Notary Public, in and for the State and County aforesaid, appeared ___________________
____________________________, and on the ______________ day of ___________________ (month)
_______ (year), executed the foregoing Durable Power of Attorney and acknowledged the same to be her
act and deed.
My commission expires:
_________________________________________
_________________________________________
Notary Public
DPofA_KY
Created 08/01; Revised 3/10 EG
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