Durable Power of Attorney for Health Care - Hawaii

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principal is personally known to me, that the principal signed or acknowledged this 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 health-care provider, nor an employee of a health-care provider or facility. I am not
related to the principal by blood, marriage, or adoption, and to the best of my knowledge, I am
not entitled to any part of the estate of the principal upon the death of the principal under a will
now existing or by operation of law.
First Witness Signature:__________________________________________________________
Date:__________________________________ Address:____________________________
Print Name:____________________________ ____________________________________
I declare under penalty of false swearing pursuant to §710-102, Hawaii Revised Statutes, that the
principal is personally known to me, that the principal signed or acknowledged this 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 health-care provider, nor an employee of a health-care provider or facility.
Second Witness Signature:________________________________________________________
Date:__________________________________ Address:____________________________
Print Name:____________________________ ____________________________________
SECOND ALTERNATIVE
NOTARY PUBLIC
State of Hawaii
County of________________________
On this ________ day of ____________________, 20_____, before me (name of notary public)
______________________________________, personally known to be (or proved to me on the
basis of satisfactory evidence) to be the person whose name is subscribed to this instrument, and
acknowledged that he or she executed it.
Notary Seal
__________________________________________
Signature of Notary Public
My commission expires:______________________
Form prepared 2001
*clerical changes made 11/05
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