The original of this document is kept at _____________________________________________________
The following individual or institution has a signed copy of this Directive:
I understand that this power of attorney exists indefinitely from the date I execute this document,
unless I establish a shorter time or revoke the power of attorney. If I am unable to make health care
decisions for myself when this power of attorney expires, the authority I have granted my agent continues
to exist until the time I become able to make health care decisions for myself. This power of attorney ends
on the following date: (if none, so state) ___________________________________________________ .
PRIOR DESIGNATIONS REVOKED:
I REVOKE ANY PRIOR DURABLE POWER OF ATTORNEY FOR HEALTH CARE.
ACKNOWLEDGMENT OF DISCLOSURE STATEMENT:
I have been provided with a disclosure statement explaining the effect of this document. I have
read and understand that information contained in the disclosure statement.
(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)
I sign my name to this durable power of attorney for health care on ____ day of _______ , _____
at __________________________________________________________ .
(City and State)
Print Name Signature
Nrsg EOL Form #2 Revised: December 26, 2002 Page 4 of 5