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Nebraska bove written. Seal _______________________________ Signature of Notary Public -2- in fact or successor attorney in fact designated by this power of attorney for health care. Witness my hand and notarial seal at _______________________________ in such county the day and year last at he or she appears in sound mind and not under duress or undue influence, that he or she acknowledges the execution of the same to be his or her voluntary act and deed, and that I am not the attorney, personally came ______________________________, personally to me known to be the identical person whose name is affixed to the above power of attorney for health care as principal, and I declare tha____ ) On this _______________________________ day of ________ , 20 ___, before me, ________________________________________________________, a notary public in and for ________________________ County________________________ ______________________________________ Date: _________________________________ Date: _________________________________ OR State of Nebraska, ) ) ss. County of _______________ney in fact by this document. Witnessed By: ______________________________________ ______________________________________ (Witness Signature) (Witness Signature) Print Name: Print Name: ______________in our presence, that the principal appears to be of sound mind and not under duress or undue influence, and that neither of us nor the principal's attending physician is the person appointed as attor/date) -1- DECLARATION OF WITNESSES We declare that the principal is personally known to us, that the principal signed or acknowledged his or her signature on this power of attorney for health care IN THIS POWER OF ATTORNEY FOR HEALTH CARE THAT THE FACT OF MY INCAPACITY IN THE FUTURE BE CONFIRMED BY A SECOND PHYSICIAN. _____________________________________ Signature of person making designation CAN REVOKE THIS POWER OF ATTORNEY FOR HEALTH CARE AT ANY TIME BY NOTIFYING MY ATTORNEY IN FACT, MY PHYSICIAN, OR THE FACILITY IN WHICH I AM A PATIENT OR RESIDENT. I ALSO UNDERSTAND THAT I CAN REQUIREAVE READ THIS POWER OF ATTORNEY FOR HEALTH CARE. I UNDERSTAND THAT IT ALLOWS ANOTHER PERSON TO MAKE LIFE AND DEATH DECISIONS FOR ME IF I AM INCAPABLE OF MAKING SUCH DECISIONS. I ALSO UNDERSTAND THAT Ied nutrition and hydration (optional): ______________________________________________________________________________ ______________________________________________________________________________ I H_____________________ ______________________________________________________________________________ I direct that my attorney in fact comply with the following instructions on artificially administer____________________________ I direct that my attorney in fact comply with the following instructions on life-sustaining treatment (optional): _________________________________________________________ttorney in fact comply with the following instructions or limitations: ______________________________________________________________________________ __________________________________________________ble of making my own health care decisions. I have read the warning which accompanies this document and understand the consequences of executing a power of attorney for health care. I direct that my a___________________, as my successor attorney in fact for health care. I authorize my attorney in fact appointed by this document to make health care decisions for me when I am determined to be incapan fact for health care. I appoint _____________________________________________________ ,whose address is __________________________________________________, and whose telephone number is _____________________________________________________________ , whose address is __________________________________________________, and whose telephone number is _______________________________, as my attorney iwith a tax professional. -2- [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -3- Power of Attorney for Health Care I appoint ____its your particular situation. You should also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed should only be a starting point for you and should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These formsney in fact withdraws pursuant to section 30-3407. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purey; duration. A power of attorney for health care shall continue in effect until the principal's death, until revoked pursuant to section 30-3420, or until the attorney in fact and any successor attorf section 30-3404. (4) A power of attorney for health care which is executed in another state and is valid under the laws of that state shall be valid according to its terms. 30-3410 - Power of attorn or any other form fully complies with the terms of section 30-3404. (3) A power of attorney for health care executed prior to January 1, 1993, shall be effective if it fully complies with the terms oincluded in a durable power of attorney drafted under the Uniform Durable Power of Attorney Act or in any other form if the power of attorney for health care included in such durable power of attorneyed on or after September 9, 1993, shall be in a form which complies with sections 30-3401 to 30-3432 and may be in the form provided in this subsection. (2) A power of attorney for health care may be (2) Each witness shall make the written declaration in substantially the form prescribed in section 30-3408. 30-3408 - Power of attorney; form; validity. (1) A power of attorney for health care execut employee of a life or health insurance provider for the principal. No more than one witness may be an administrator or employee of a health care provider who is caring for or treating the principal. ttorney for health care: The principal's spouse, parent, child, grandchild, sibling, presumptive heir, known devisee at -1- the time of the witnessing, attending physician, or attorney in fact; or anefore a notary public who shall not be the attorney in fact or successor attorney in fact. 30-3405 - Witness; disqualification; declaration. (1) The following shall not qualify to witness a power of aes either the signing and dating of the power of attorney for health care by the principal or the principal's acknowledgment of the signature and date, or be signed and acknowledged by the principal balth care decisions on behalf of the principal in the event the principal is incapable, (4) show the date of its execution, and (5) be witnessed and signed by at least two adults, each of whom witnesstorney for health care shall (1) be in writing, (2) identify the principal, the attorney in fact, and the successor attorney in fact, if any, (3) specifically authorize the attorney in fact to make heuting a power of attorney for health care unless such adult has been adjudged incompetent or unless a guardian has been appointed for such adult. 30-3404 - Power of attorney; contents. The power of at of the successor attorney in fact shall cease and the authority of the original designee shall commence. (2) There shall be a rebuttable presumption that every adult is competent for purposes of exec attorney in fact. If, after the authority of a successor attorney in fact has commenced, the original attorney in fact becomes available, able, and willing to serve as attorney in fact, the authoritympetent adult as a successor attorney in fact to serve in place of the original attorney in fact when the original attorney in fact is not reasonably available or is unable or unwilling to serve as anrney for health care thereby designating another competent adult as attorney in fact for health care decisions in accordance with sections 30-3401 to 30-3432. A principal may also designate another co Statutes relating to the Nebraska Power of Attorney for Health Care Form. 30-3403 - Power of attorney for health care; designation; competency; presumption. (1) A principal may confer a power of attorney for Health Care Form. This Nebraska Power of Attorney for Health Care is based on Chapter 30 Section 30-3410 et. Seq. of the Nebraska Statutes. The following are useful excerpts from the NebraskaInformation and Instructions Nebraska Power of Attorney for Health Care This package contains (1) Information and Instruction for Nebraska Power of Attorney for Health Care; (2) Nebraska Power of Atto Nebraska