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I further declare that I am not a relative of the principal by blood, marriage, or adoption (within
the third degree of consanguinity).
(signature of first OR second witness
SECOND ALTERNATIVE: NOTARIZATION
State of Iowa )
County of ________________________________ )
Signed and sworn to before me by__________________________________________________,
this _________________ day of ___________________________________________, 20____.
Signature of Notary Public
OPTIONAL (BUT RECOMMENDED)
I state that the person this document designates as my attorney in fact (my agent) to make health
care decisions for me has been notified of and has consented to the designation.
Signature of Principal
form prepared 2001
*clerical changes made 11/05