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Sample Health Care Durable Power of Attorney
(Name), (SS No.), (Address), herewith appoints his/her son/daughter, (Name), (Address, if willing and able to serve, as my attorneys-in-fact, to act in my place and stead and with the same authority as I would have to do the following acts:
In the event of my incapacity, to act in my place regarding any and all health care decisions for me, including the type of treatment, location of treatment, and in addition, the right to refuse or decline life prolonging treatment and to direct that any care which I receive be solely to alleviate pain, all in accordance with the fully executed, witnessed and notarized Uniform Living Will of (Name) which is attached and made a part thereof of this power of attorney.
This is a durable power of attorney and shall not terminate upon my incapacity. this power of attorney shall be in effect from Upon incapacitation of Executor to Upon death of Executor. However, should I be incapacitated or incompetent at the time stated for expiration (Upon death of Executor), this power shall extend until I am no longer incapacitated.
_____________________________________________________
(Name)
_________________________________
Date
AFFIDAVIT
STATE OF )
COUNTY OF )
(Name), (SS No.), being duly sworn, or having affirmed to tell the truth, personally appeared this day before me, the undersigned authority authorized to take acknowledgments and administer oaths, and stated that he/she is competent under the law to give this affidavit and this power of attorney as a voluntary act and deed and that he/she has personal knowledge of the facts contained herein.
Sworn or affirmed before me on _____________________
____________________________________________
(Name), (SS No.)
______________________________________________
Notary Public
If you have any questions regarding the information in this document, please consult your legal professional. |
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