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Power of Attorney for
Health Care
I, the undersigned
(Full legal name)
______________________________
(Identity number)
______________________________ residing at
(Address)
____________________________________
____________________________________
revoke any and all previous Power of
Attorney for Health Care made by me and
appoint
(Full legal name)
________________________________
(Identity number)
______________________________ residing at
(Address)
____________________________________
____________________________________
to be my Agent for my health and personal
care.
If my Agent is unable or unwilling to
serve, I appoint
(Full legal name)
________________________________
(Identity number)
______________________________ residing at
(Address)
____________________________________
____________________________________
as substitute agent for my health and
personal care.
1. I direct my Agent to make health care
decisions according to my wishes as set out in
my Health Care Directive (Living Will)
attached hereto.
2. I further authorize my Agent to make
personal care decisions for me if I am
mentally unable to do so.
3. This Power of Attorney for Health Care
shall take effect when I become unable to make
my own health care decisions and it shall
remain in full force and effect until my death
unless I revoke it.
Executed this ______ day of
__________________20 ____
at ______________________________________
Signature: ________________________________
in the presence of the undersigned
witnesses:
Declaration of
Witnesses
As witnesses we
declare that the above named person is
personally known to us, appears to be of sound
mind and signed this directive willingly and
free of undue influence or duress. We are
legal adults and are not related to him / her
by blood, marriage or adoption and are not
appointed as agents in this directive. To our
knowledge we are not beneficiaries of his /
her estate and have no claims against his /
her estate. We are not directly involved in
his / her health care. We declare that he /
she signed this will in our presence as we
signed as witnesses in the presence of each
other, all being present at the same time.
Under penalty of perjury we declare these
statements to be true and correct on this
___________________ day of
____________________ 20____ at
_________________________________.
Witness 1.
Name:
______________________
Address:
_____________________________________________
Signature:
________________________
Witness 2.
Name:
______________________
Address:
_____________________________________________
Signature:
________________________ |
