Nebraska Power of Attorney Health Care POWER OF ATTORNEY FOR HEALTH CARE I, in fact for health care: Name: _____________________________________________ Address: Phone Number: _____________________________________ (your name) name the following person as my attorney SUCCESSOR TO POWER OF ATTORNEY FOR HEALTH CARE If my agent (above) is unwilling or unable to act, I appoint the following person as my successor power of attorney for health care: Name:_____________________________________________ Address: Phone number:______________________________________ By initialing the below, I acknowledge that I have read and understand each statement and the consequences of executing a power of attorney for health care. I authorize my attorney in fact for health care appointed by this document to make health care decisions for me when I am determined to be incapable of making my own health care decisions I direct that my attorney in fact for health care comply with the following instructions or limitations:______________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Page 1 of 3 Power of Attorney, DC 6:13 PSC, Rev. 03/16 §30-3408 American LegalNet, Inc. www.FormsWorkFlow.com I direct that my attorney in fact for health care comply with the following instructions on lifesustaining treatment: (optional) limitations:_______________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ I direct that my attorney in fact for health care comply with the following instructions on artificially administered nutrition and hydration: (optional) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ I have 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 I can revoke this power of attorney for health care at any time by notifying my attorney in fact for health care, my physician, or the facility in which I am a patient or resident. I also understand that I can require in this power of attorney for health care that the fact of my incapacity in the future be confirmed by a second physician. I have read the above warning which accompanies this document and understand the consequences of executing a power of attorney for health care. _______________________________________________ Signature of person making designation _______________________________________ Date Do not sign this form until you are in the presence of either the two witnesses or a Notary. Page 2 of 3 Power of Attorney, DC 6:13 PSC, Rev. 03/16 §30-3408 American LegalNet, Inc. www.FormsWorkFlow.com DECLARATION OF WITNESSES We declare that the individual signing this power of attorney for health care is personally known to us, has signed or acknowledged his or her signature on this power of attorney for health care in our presence, and appears to be of sound mind and not under duress or undue influence. Furthermore, neither of us, nor the principal's attending physician, is the person appointed as attorney in fact for health care by this document. Witnessed By: (Signature of Witness/Date) (Printed Name of Witness) (Signature of Witness/Date) (Printed Name of Witness) OR NOTARY State of Nebraska [County] of ) ) ss. ) This document was acknowledged before me on by _________________________________ (Name of Principal) . __________________, (Date) _________________________________________ Signature of Notary My commission expires: (Seal, if any) Page 3 of 3 Power of Attorney, DC 6:13 PSC, Rev. 03/16 §30-3408 American LegalNet, Inc. www.FormsWorkFlow.com