Health Care Power Of Attorney Form - South Carolina (Page 6 of 7) in pdf

HAVE AUTHORITY TO DIRECT THAT NUTRITION AND HYDRATION NECESSARY FOR

COMFORT CARE OR ALLEVIATION OF PAIN BE WITHDRAWN.

9. ADMINISTRATIVE PROVISIONS

I revoke any prior Health Care Power of Attorney and any provisions relating to health care of any

other prior power of attorney.

B. This power of attorney is intended to be valid in any jurisdiction in which it is presented.

BY SIGNING HERE I INDICATE THAT I UNDERSTAND THE CONTENTS OF THIS

DOCUMENT AND THE EFFECT OF THIS GRANT OF POWERS TO MY AGENT.

I sign my name to this Health Care Power of Attorney on

this ____________ day of ___________________, 20 ____. My current home address is:

_____________________________________________________________________________

Principal's Signature:____________________________________________________________

Print Name of Principal:__________________________________________________________

I declare, on the basis of information and belief, that the person who signed or acknowledged this

document (the principal) is personally known to me, that he/she signed or acknowledged this Health

Care Power of Attorney in my presence, and that he/she appears to be of sound mind and under no

duress, fraud, or undue influence. I am not related to the principal by blood, marriage, or adoption, either

as a spouse, a lineal ancestor, descendant of the parents of the principal, or spouse of any of them. I am

not directly financially responsible for the principal's medical care. I am not entitled to any portion of the

principal's estate upon his decease, whether under any will or as an heir by intestate succession, nor am I

the beneficiary of an insurance policy on the principal's life, nor do I have a claim against the principal's

estate as of this time. I am not the principal's attending physician, nor an employee of the attending

physician. No more than one witness is an employee of a health facility in which the principal is a

patient. I am not appointed as Health Care Agent or Successor Health Care Agent by this document.

Witness No. 1

Signature:________________________________________________________________________

Date:____________________________________________________________________________

Print Name:______________________________________________________________________

Telephone:_______________________________________________________________________

Address:_________________________________________________________________________

________________________________________________________________________________

Witness No. 2