North Dakota Health Care Power of Attorney Form - Free Download | Page 5
The North Dakota health care power of attorney is a legal document used by the grantor to authorize the attorney-in-fact to make decisions about his/her health care matters.
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(Insert name, address, and telephone number of second alternate agent.)
9. PRIOR DESIGNATIONS REVOKED. I revoke any prior durable power of attorney
for health care.
DATE AND SIGNATURE OF PRINCIPAL
(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)
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 NOTARIZED
OR SIGNED BY TWO 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.)
NOTARY PUBLIC OR STATEMENT OF WITNESSES
This document must be (1) notarized or (2) witnessed by two qualified adult witnesses.
The person notarizing this document may be an employee of a health care or long-term
care provider providing your care. At least one witness to the execution of the document
must not be a health care or long-term care provider providing you with direct care or an
employee of the health care or long-term care provider providing you with direct care.
None of the following may be used as a notary or witness:
1. A person you designate as your agent or alternate agent;
2. Your spouse;
3. A person related to you by blood, marriage, or adoption;
4. A person entitled to inherit any part of your estate upon your death; or
5. A person who has, at the time of executing this document, any claim against your
estate.
Option 1: Notary Public
In my presence on __________ (date), ________________ (name of declarant)
acknowledged the declarant's signature on this document or acknowledged that the
declarant directed the person signing this document to sign on the declarant's behalf.
_________________________
