North Dakota Health Care Power of Attorney Form - Free Download | Page 6
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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(Signature of Notary Public)
My commission expires __________________________ , 20__.
Option 2: Two Witnesses
Witness One:
(1) 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.
(2) I am at least eighteen years of age.
(3) If I am a health care provider or an employee of a health care provider giving direct
care to the declarant, I must initial this box: [_______].
I certify that the information in (1) through (3) is true and correct.
_________________________
(Signature of Witness One)
_________________________
(Address)
Witness Two:
(1) 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.
(2) I am at least eighteen years of age.
(3) If I am a health care provider or an employee of a health care provider giving direct
care to the declarant, I must initial this box: [______].
I certify that the information in (1) through (3) is true and correct.
_________________________
(Signature of Witness Two)
_________________________
(Address)
