Statement of Witnesses
You should carefully read and follow this witnessing procedure . This document will not be valid unless you comply with the witnessing procedure . If you elect to use witnesses instead of having this document notarized , you must use two qualified adult witnesses . None of the following may be used as witnesses : ( 1 ) a person you designate as Attorney-In-Fact ; ( 2 ) a provider of healthcare ; ( 3 ) an employee of a provider of healthcare ; ( 4 ) the operator of a healthcare facility ; ( 5 ) an employee of an operator of a healthcare 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 principal is personally known to me , that the principal signed or acknowledged the Durable Power of Attorney in my presence , that the principal appears to be of sound mind and under no duress , fraud , or undue influence , that I am not the person appointed as Attorney-In-Fact by this document , and that I am not a provider of healthcare , an employee of a provider of healthcare , the operator of community care facility , nor an employee of an operator of a healthcare facility .
Signature : ________________________________________________________________ Date : _____________________________ Print Name : _________________________________________________________________________________________________ Residence Address : __________________________________________________________________________________________
Signature : ________________________________________________________________ Date : _____________________________ Print Name : _________________________________________________________________________________________________ Residence Address : __________________________________________________________________________________________
At least one of the above witnesses must also sign the following declaration .
I declare under penalty of perjury that I am not related to the principal by blood , marriage or adoption , and to the best of my knowledge I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law .
Signature : ________________________________________________________________ Date : _____________________________ Print Name : _________________________________________________________________________________________________ Residence Address : __________________________________________________________________________________________
Signature : ________________________________________________________________ Date : _____________________________ Print Name : _________________________________________________________________________________________________ Residence Address : __________________________________________________________________________________________
Copies : You should retain an executed copy of this document and give one to your Attorney-In-Fact . The Power of Attorney should be available so a copy may be given to your providers of healthcare . This includes requesting the Nevada Secretary of State to electronically store this document with the Nevada Lockbox to allow access by authorized providers of healthcare . ( Added to NRS by 1987 , 915 ; A991 , 638 , 1564 ; 1993 , 562 , 2793 )
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