Fill and Sign the Medical Power Attorney Form

AFFIDAVIT OF MEDICAL DOCTOR AS TO INCAPACITY OF PERSON IN ORDER FOR POWER OF ATTORNEY TO BECOME EFFECTIVE AFFIDAVIT State of ____________________ County of ___________________ __________________________________ (Name of Physician) , being first sworn, deposes and says: 1. I am a practicing physician licensed by __________________________________ (name of licensing state) as a medical doctor and specialize in ___________________________________ (e.g., family medicine). 2. On _________________ (date), I made a physical and mental examination of ____________________________________ (name of person with incapacity) at the request of __________________________________ (name of interested person, e.g., daughter). 3. As a result of said examination, it is my opinion as a practicing physician licensed by _____________________ (name of licensing state) as a medical doctor, that __________________________________ (name of person with incapacity) : ( ) is, by reason of advanced age, physical incapacity or mental weakness, incapable of managing his or her own estate. ( ) lacks the mental capacity to enter into a binding agreement or make decisions on his or her own behalf. ( ) does not have the ability to understand that a contract is being made and its general nature. 4. All the facts and opinions stated in this affidavit are true and correct to the best of undersigned’s knowledge and belief. Witness my signature this _____ day of _______________ , ______ . __________________________________ (Printed Name & Signature of Physician) Sworn to and subscribed by ____________________ (Name of Physician) before me this _______________________ (date). _________________________________ Notary Public My Commission Expires: ______________________