North Carolina Statutory Form Health Care Power Of Attorney Page 6
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118. Signature of principal.
By signing here, I indicate that I am mentally alert and competent, fully informed as to the
contents of this document, and understand the full import of this grant of powers to my
health care agent.
(SEAL)
Signature of Principal _____________________________ Date _________________
9. Signatures of Witnesses.
I hereby state that the Principal, ______________________, being of sound mind, signed
the foregoing health care power of attorney in my presence, and that I am not related to the
principal by blood or marriage, and I would not be entitled to any portion of the estate of
the principal under any existing will or codicil of the principal or as an heir under the
Intestate Succession Act, if the principal died on this date without a will. I also state that I
am not the principal's attending physician, nor an employee of the principal's attending
physician, nor an employee of the health facility in which the principal is a patient, nor an
employee of a nursing home or any group care home where the principal resides. I further
state that I do not have any claim against the principal.
Witness: ___________________ Date: __________
Witness: ___________________ Date: __________
STATE OF NORTH CAROLINA
COUNTY OF___________________
CERTIFICATE
I, __________, a Notary Public for _________ County, North Carolina, hereby certify that
__________ appeared before me and swore to me and to the witnesses in my presence that
this instrument is a health care power of attorney, and that he/she willingly and voluntarily
made and executed it as his/her free act and deed for the purposes expressed in it.
I further certify that _____________ and _____________, witnesses, appeared before me
and swore that they witnessed ________________ sign the attached health care power of
attorney, believing him/her to be of sound mind; and also swore that at the time they
witnessed the signing (i) they were not related within the third degree to him/her or his/her
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