Durable Power of Attorney for Health Care - Texas

STATEMENT OF WITNESSES:
I declare under penalty of perjury that the principal has identified himself or herself to me, that
the principal signed or acknowledged this durable power of attorney in my presence, that I believe the
principal to be of sound mind, that the principal has affirmed that the principal is aware of the nature of
the document and is signing it voluntarily and free from duress, that the principal requested that I serve as
witness to the principal's execution of this document, that I am not the person appointed as agent by this
document and that I am not a provider of health or residential care, or an employee of an operator of a
health care facility.
I declare 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 principal on the death of the principal under a
will or by operation of law.
Witness Signature: _____________________________________________________________________
Print Name: ______________________________________ Date: _______________________________
Address: _____________________________________________________________________________
Witness Signature: _____________________________________________________________________
Print Name: ______________________________________ Date: _______________________________
Address: _____________________________________________________________________________
Nrsg EOL Form #2 Revised: December 26, 2002 Page 5 of 5
Page 5/5
Free Download

Durable Power of Attorney for Health Care - Texas PDF

Favor this template? Just fancy it by voting!
  •  
  •  
  •  
  •  
  •  
(0 Votes)
0.0
Related Forms
  •  
  •  
  •  
  •  
  •  
2 Page(s) | 1241 Views | 4 Downloads
  •  
  •  
  •  
  •  
  •  
1 Page(s) | 898 Views | 7 Downloads
  •  
  •  
  •  
  •  
  •  
2 Page(s) | 1159 Views | 5 Downloads
  •  
  •  
  •  
  •  
  •  
7 Page(s) | 2614 Views | 9 Downloads
  •  
  •  
  •  
  •  
  •  
3 Page(s) | 1144 Views | 1 Downloads