Living Will Or Health Care Instructions Form (Page 4 of 4) in pdf

Living Will Or Health Care Instructions Form Page 4

OPTIONAL FORM

WITNESSES' AFFIDAVITS

STATE OF CONNECTICUT

)

:ss.__________________________

)

(Town)

COUNTY OF ____________________________

)

We, the subscribing witnesses, being duly sworn, say that we witnessed the execution of this

living will or health care instructions by the author of this document; that the author subscribed,

published and declared the same to be the author's instructions, appointments and designation

in our presence; that we thereafter subscribed the document as witnesses in the author's

presence, at the author's request and in the presence of each other; that at the time of the

execution of said document the author appeared to us to be eighteen years of age or older, of

sound mind, able to understand the nature and consequences of said document, and under no

improper influence, and we make this affidavit at the author's request this _____ day of

_____________________, 20____.

x_____________________________

x_______________________________

(Witness)

x_____________________________

x_______________________________

(Number and Street)

x_____________________________

x_______________________________

(City, State and Zip Code)

Subscribed and sworn to before me by ___________________and ______________________,

the signing witnesses to the foregoing affidavit this ______ day of _________________,

20____.

_________________________________

Commissioner of the Superior Court

Notary Public

My Commission expires: _____________

(Print or type name of all persons signing under all signatures)

Living Will Or Health Care Instructions Form Page 4