Durable Power of Attorney Example - Washington
Certification of Incapacity
(Certification by Qualified Physicians in the Absence of a Regular Attending
Physician)
The undersigned each certify that he/she is a medical doctor, that he/she has examined
the principal and reviewed the principal’s medical history, and that in the opinion of the
undersigned, 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: _______________________________________
dated: _________________________
_______________________________
signature
printed name: ______________________________
address: _______________________________________
________________________________________
________________________________________
telephone: _______________________________________
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