Durable Power of Attorney for Health Care Decisions - Nevada

162A.860. Power of attorney: Form, NV ST 162A.860
STATEMENT OF WITNESSES
(You should carefully read and follow th is witnessin g proced ure. This docu ment will no t be valid un less you co mply with th e
witnessing procedure. If you elect to use wit nesses instead of having t his doc ument nota rized, yo u must use tw o qualifi ed adult
witnesses. None of the following may be used as a witness: (1) a person you designate as the agent; (2) a provider of health
care; (3) an employee of a provider of health care; (4) the operator of a h ealth care facility; or (5) an employee of an operator
of a health care facility. At least one of the witnesses must make the ad ditional declaration set out following the place where
the witnesses sign.)
I declare under penalty of perjury that the principal is personally known to me, that the principal signed or
acknowledged this durable power of attorney in my presence, that the principal appears to be of sound mind and under no
duress, fraud or undue influence, that I am not the person appointed as agent by this document and that I am not a provider of
health care, an employee of a provider of health care, the operator of a health care facility or an emplo yee of an operator of a
health care facility.
Signature: _______________________________________
Print Name: ______________________________________
Date: ________ ___________________________________
Residential Address: _______________________________
________________________________________________
________________________________________________
Signature: _______________________________________
Print Name: ______________________________________
Date: ________ ___________________________________
Residential Address: _______________________________
________________________________________________
________________________________________________
(AT LEAST ONE OF THE ABOVE WIT N E SSES MUS T ALSO SI G N THE FO LLO WI NG DECL ARATION.)
I declare under penalty of perjury that I am not related to the principal by blood, marriage or adoption and that to the
best of my knowledge, I am not entitled to any part of the estate of the prin cipal upon the death of the princip al under a will
now existin g or by operation of la w.
Signature:
Signature:
Names: _______________ ___ ___ ___ ______ ___ ___ ___ __
Print Name: ______________________________________
Date: ________ ___________________________________
Address: __________________________ ______________
________________________________________________
________________________________________________
COPIES: You should retain an executed cop y of th is document and g ive on e to you r ag en t. The power of attorn ey sh ou ld be
available so a copy may be given to your providers of health care.
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