Durable Power of Attorney for Health Care and Living Will

VA FORM
10-0137
Page 6 of 7
JUL 2015
City, State, Zip:
Street Address:
VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
NAME (Last, First, Middle) LAST FOUR DIGITS OF SSN:
B - WITNESSES' SIGNATURES
Two people must witness your signature. VA employees may be witnesses if they are members of:
l
The Chaplain Service
l
The Social Work Service
l Nonclinical employees (e.g., Medical Administration Service, Voluntary Service, or Environmental
Management Service)
Other employees of your VA facility may not sign as witnesses to your advance directive unless they’re in your family.
Witness #1
Name (Printed or Typed):
SIGNATURE:
DATE:
Witness #2
City, State, Zip:
Street Address:
Name (Printed or Typed):
SIGNATURE:
DATE:
I personally witnessed the signing of this advance directive. I am not appointed as Health Care Agent in this
advance directive. I am not financially responsible for the care of the person making this advance directive.
To the best of my knowledge, I am not named in the person’s will.
I personally witnessed the signing of this advance directive. I am not appointed as Health Care Agent in this
advance directive. I am not financially responsible for the care of the person making this advance directive.
To the best of my knowledge, I am not named in the person's will.
A - YOUR SIGNATURE
PART IV: SIGNATURES
SIGNATURE
DATE
By my signature below, I certify that this form accurately describes my preferences.
Page 6/7
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