Health Care Power of Attorney Form - Delaware

Advance Health Care Directive of ________________________________________________________ Page 6
req uest, and in the presence of each ot her, have hereunto subscribed our names as witnesses,
and stat e:
A. The Declarant is m entally competent.
B. That neit her of us is prohibit ed by §2503 of Title 16 of the Delaware Code fr om
being a witness. Neit her of us:
1. Is related t o t he declarant by blood, m ar r iage or adoption;
2. Is ent it led to any portion of the est at e of the declar ant under any will of
the declar ant or codicil ther et o t hen existing nor , at the t ime of the
executing of the advance health car e dir ective, is so entitled by operation
of law then existing;
3. Has, at t he time of the execution of the advance health care dir ective, a
present or inchoat e claim ag ainst any portion of the est at e of the
declarant;
4. Has a direct financial responsibilit y for t he declarant ' s m edical car e;
5. Has a controlling int erest in or is an oper at or or an employee of a
health car e inst itut ion in which the declarant is a patient or r e sident ; or
6. Is under eight een years of age.
C. That if the declarant is a resident of a sanitarium, rest home, nursing home,
boarding home or related institution, one of the witnesses, __________________
___________________, is at the time of the execution of the advance health care
directive, a patient advocate or ombudsman designated by the Division of Services
for Aging and Adults with Physical Disabilities or the Public G uar dian.
Witness Witness
__________________________________ __________________________________
(print name) (print name)
__________________________________ __________________________________
(address) (address)
__________________________________ __________________________________
(ci ty, st ate, zi p code) (ci ty, st ate, zi p code)
__________________________________ __________________________________
(si gnat ure of witnes s) (date) (si gnat ure of witnes s) (date)
(Optional)
Sworn and subscr ibed t o m e this _____ day of _________________________.
My term expires: _______________________ __________________________________
(Notary)
Page 6/6
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Health Care Power of Attorney Form - Delaware PDF

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