AFFIDAVIT OF MEDICAL DOCTOR AS TO INCAPACITY OF PERSON IN ORDER FOR POWER OF ATTORNEY TO BECOME EFFECTIVE State of County of (Name of Physician), being first sworn, deposes and says: I am a practicing physician licensed by (Insert name of the licensing state) as a medical doctor and specialize in (describe the specialization). I made a physical and mental examination of (name of patient with incapacity) at the request of his/her (insert relation) Mr/Mrs (name of interested person,). After Examining the said patient I as practicing physician licensed by the state of came to an opinion that (insert name of the patient). ( ) 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. 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 American LegalNet, Inc. 251 www.FormsWorkFlow.com (date). Notary Public Name My Commission Expires: