Logan County Advance Directive Form (Page 4 of 4) in pdf

Logan County Advance Directive Form Page 4

WITNESSES’ AFFIDAVITS

STATE OF ILLINOIS

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COUNTY OF LOGAN

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We, the subscribing witnesses, being duly sworn, say that we witnessed the execution of these health

care instructions, the appointments of a health care agent and an attorney-in-fact, and the designation

of a conservator for future incapacity by the author of these Advanced Directives that the author

subscribed, published and declared the same to be the author’s instructions, appointments, and

designation in our presence; that we thereafter subscribed these documents as witnesses at the

author’s request, in the author’s presence, and in the presence of each other; that at the time of the

execution of said documents, the author appeared to us to be eighteen years of age or older, of

sound mind, able to understand the nature and consequences of said documents, and under no

undue influence to execute said documents; and that we will make this affidavit at the author’s

request this __________ day of _____________________, 20___.

____________________________________

_____________________________________

(Witness)

Subscribed and sworn to before me this _________ day of ________________________, 20 ___.

____________________________________________________

Logan County Clerk of the Circuit Court

Notary Public

My Commission Expires ________________________________

(Print or type name of each person signing under the respective signature.)

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Logan County Advance Directive Form Page 4