Durable Power of Attorney Example - Washington

Certification of Incapacity
(Certification by Agent)
I certify that the principal lacks the mental capacity to make important decisions
independently.
dated: _________________________
_______________________________
signature
printed name: ______________________________
address: _______________________________________
________________________________________
________________________________________
telephone: _______________________________________
Certification of Incapacity
(Certification by Regular Attending Physician)
I certify that I am a medical doctor, that I have regularly attended the principal and in my
opinion the principal is now incompetent or disabled as defined in paragraph 1 of this
document due to a lack of mental capacity to make important decisions independently
and/or for the following reason:
dated: _________________________
_______________________________
signature
printed name: ______________________________
address: _______________________________________
________________________________________
________________________________________
telephone: _______________________________________
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