Statutory and Durable Health Care Power of Attorney - Rhode Island

I sign my name to this Statutory Form Durable Power of Attorney for
Health Care on _________________ (Date) at
_____________________ (City), _____________________________ (State)
_______________________________ (You sign here)
(THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS
SIGNED BY TWO (2) QUALIFIED WITNESSES WHO ARE PRESENT
WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE. IF YOU
HAVE ATTACHED ANY ADDITIONAL PAGES TO THIS FORM, YOU
MUST DATE AND SIGN EACH OF THE ADDITIONAL PAGES AT THE
SAME TIME YOU DATE AND SIGN THIS POWER OF ATTORNEY.)
STATEMENT OF WITNESSES
(This document must be witnessed by two (2) quali7ed adult
witnesses. None of the following may be used as a witness:
(1) A person you designate as your agent or alternate agent,
(2) A health care provider,
(3) An employee of a health care provider,
(4) The operator of a community care facility,
(5) An employee of an operator of a community care facility.
At least one of the witnesses must make the additional declaration
set out following the place where the witnesses sign.)
I declare under penalty of perjury that the person who signed or
acknowledged this document is personally known to me to be the
principal, that the principal signed or acknowledged this durable
power of attorney in my presence, that the principal appears to be of
sound mind and under no duress, fraud, or undue inJuence, that I am
not the person appointed as attorney in fact by this document, and
that I am not a health care provider, an employee of a health care
provider, the operator of a community care facility, nor an employee of
an operator of a community care facility.
Signature: ______________________ Residence Address:
________________________________
Page 6/7
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Statutory and Durable Health Care Power of Attorney - Rhode Island DOC

Statutory and Durable Health Care Power of Attorney - Rhode Island PDF

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