NOTES FOR COMPLETION 2 COLUMNS - Health and Social Services
NOTES FOR COMPLETION 2 COLUMNS - Health and Social Services
NOTES FOR COMPLETION 2 COLUMNS - Health and Social Services
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11. (Optional) I have attached <strong>and</strong> included in this Directive:<br />
(Initial beside the Attachments you have attached.)<br />
A. Attachment A outlining my wishes.<br />
B. Attachment B outlining additional authority I wish to give to my proxy(ies).<br />
C. Attachment<br />
12. SIGNATURE OF MAKER<br />
I sign this document while capable of underst<strong>and</strong>ing the nature <strong>and</strong> effect of this<br />
Directive.<br />
My signature<br />
Date<br />
Month/Day/Year<br />
(OR if you are mentally capable but for some reason unable to sign, you may direct<br />
another person to complete <strong>and</strong> sign this Directive on your behalf in your presence.<br />
The person signing CANNOT be the proxy or the spouse of the proxy.)<br />
Signature on my behalf<br />
Relationship to Maker<br />
Date<br />
Month/Day/Year<br />
SIGNATURES OF WITNESSES<br />
(Two adults 19 years or older must witness your signature <strong>and</strong> sign together in your<br />
presence.)<br />
I certify that I witnessed the signing of this Directive by the Maker in my presence.<br />
I am not a proxy or the spouse of a proxy.<br />
Witness<br />
Signature<br />
Date<br />
Month/Day/Year<br />
Witness<br />
Signature<br />
Date<br />
Month/Day/Year<br />
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