Health Powers of Attorney Form: Created 1/15/09 Page 2 of 2
CHECK ONE OF THE FOLLOWING BOXES:
This power of attorney shall terminate upon my disability, incapacity or incompetence.
This power of attorney is effective immediately, and shall not be affected by my disability, incapacity or
This power of attorney will become effective upon my disability, incapacity or incompetence.
I understand that in accordance with Indiana Code 30-5-10-1, except as otherwise stated in this power of attorney
form, this executed power of attorney may be revoked only in writing wherein the written revocation statement
identifies the power of attorney revoked and is signed by myself, the principal. This power of attorney shall continue
in full force and effect until I have executed and recorded in the Recorder’s Office of the county of my domicile a
written revocation hereof.
Signed this ________ day of _______________, _________.
(Your signature) (Your social security number)
State of __________________. County of ________________.
On this _____________day of ______________________, ________, before me personally appeared
______________________________________ (name of principal), who is personally known to me or provided
______________________________________________as identification, and acknowledged that he or she
executed this health powers of attorney form.