GENERAL ASSEMBLY OF NORTH CAROLINA
SESSION 2015
H 1
HOUSE BILL 146
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Short Title: Amend Advance Health Care Directives Laws. |
(Public) |
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Sponsors: |
Representatives Lambeth, Jones, Conrad, and Ross (Primary Sponsors). For a complete list of Sponsors, refer to the North Carolina General Assembly Web Site. |
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Referred to: |
Judiciary I. |
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March 4, 2015
A BILL TO BE ENTITLED
AN ACT eliminating the need to have advance health care directives and health care powers of attorney SIGNED in the presence of two witnesses and ACKNOWLEDGED BEFORE a notary public, and instead allowing FOR EXECUTION BY EITHER SIGNATURE in the presence of two witnesses or ACKNOWLEDGMENT BEFORE a notary public.
The General Assembly of North Carolina enacts:
SECTION 1. G.S. 32A‑16(3) reads as rewritten:
"(3) Health care power of attorney. – A written
instrument that substantially meets the requirements of this Article, that is
signed in the presence of two qualified witnesses, andwitnesses, or
acknowledged before a notary public, pursuant to which an attorney‑in‑fact
or agent is appointed to act for the principal in matters relating to the
health care of the principal. The If notarized, the notary who
takes the acknowledgement may but is not required to be a paid employee of the
attending physician or mental health treatment provider, a paid employee of a
health facility in which the principal is a patient, or a paid employee of a
nursing home or any adult care home in which the principal resides."
SECTION 2. G.S. 32A‑25.1(a) reads as rewritten:
"(a) The use of the following form in the creation of a health care power of attorney is lawful and, when used, it shall meet the requirements of and be construed in accordance with the provisions of this Article:
HEALTH CARE POWER OF ATTORNEY
NOTE: YOU SHOULD USE THIS DOCUMENT TO NAME A PERSON AS YOUR HEALTH CARE AGENT IF YOU ARE COMFORTABLE GIVING THAT PERSON BROAD AND SWEEPING POWERS TO MAKE HEALTH CARE DECISIONS FOR YOU. THERE IS NO LEGAL REQUIREMENT THAT ANYONE EXECUTE A HEALTH CARE POWER OF ATTORNEY.
EXPLANATION: You have the right to name someone to make health care decisions for you when you cannot make or communicate those decisions. This form may be used to create a health care power of attorney, and meets the requirements of North Carolina law. However, you are not required to use this form, and North Carolina law allows the use of other forms that meet certain requirements. If you prepare your own health care power of attorney, you should be very careful to make sure it is consistent with North Carolina law.
This document gives the person you designate as your health care agent broad powers to make health care decisions for you when you cannot make the decision yourself or cannot communicate your decision to other people. You should discuss your wishes concerning life‑prolonging measures, mental health treatment, and other health care decisions with your health care agent. Except to the extent that you express specific limitations or restrictions in this form, your health care agent may make any health care decision you could make yourself.
This form does not impose a duty on your health care agent to exercise granted powers, but when a power is exercised, your health care agent will be obligated to use due care to act in your best interests and in accordance with this document.
This Health Care Power of Attorney form is intended to be valid in any jurisdiction in which it is presented, but places outside North Carolina may impose requirements that this form does not meet.
If you want to use this form,
you must complete it, sign it, and have your signature witnessed by two
qualified witnesses and or proved by a notary public.
Follow the instructions about which choices you can initial very carefully. Do
not sign this form until two witnesses and or a notary public
are present to watch you sign it. You then should give a copy to your health
care agent and to any alternates you name. You should consider filing it with
the Advance Health Care Directive Registry maintained by the North Carolina
Secretary of State: http://www.nclifelinks.org/ahcdr/
1. Designation of Health Care Agent.
I, __________________, being of sound mind, hereby appoint the following person(s) to serve as my health care agent(s) to act for me and in my name (in any way I could act in person) to make health care decisions for me as authorized in this document. My designated health care agent(s) shall serve alone, in the order named.
A. Name: _______________________ Home Telephone: _______________
Home Address: _______________________ Work Telephone: _______________
____________________________________ Cellular Telephone: _______________
B. Name: _______________________ Home Telephone: _______________
Home Address: _______________________ Work Telephone: _______________
____________________________________ Cellular Telephone: _______________
C. Name: _______________________ Home Telephone: _______________
Home Address: _______________________ Work Telephone: _______________
____________________________________ Cellular Telephone: _______________
Any successor health care agent designated shall be vested with the same power and duties as if originally named as my health care agent, and shall serve any time his or her predecessor is not reasonably available or is unwilling or unable to serve in that capacity.
2. Effectiveness of Appointment.
My designation of a health care agent expires only when I revoke it. Absent revocation, the authority granted in this document shall become effective when and if one of the physician(s) listed below determines that I lack capacity to make or communicate decisions relating to my health care, and will continue in effect during that incapacity, or until my death, except if I authorize my health care agent to exercise my rights with respect to anatomical gifts, autopsy, or disposition of my remains, this authority will continue after my death to the extent necessary to exercise that authority.
1. _______________________ (Physician)
2. _______________________ (Physician)
If I have not designated a physician, or no physician(s) named above is reasonably available, the determination that I lack capacity to make or communicate decisions relating to my health care shall be made by my attending physician.
3. Revocation.
Any time while I am competent, I may revoke this power of attorney in a writing I sign or by communicating my intent to revoke, in any clear and consistent manner, to my health care agent or my health care provider.
4. General Statement of Authority Granted.
Subject to any restrictions set forth in Section 5 below, I grant to my health care agent full power and authority to make and carry out all health care decisions for me. These decisions include, but are not limited to:
A. Requesting, reviewing, and receiving any information, verbal or written, regarding my physical or mental health, including, but not limited to, medical and hospital records, and to consent to the disclosure of this information.
B. Employing or discharging my health care providers.
C. Consenting to and authorizing my admission to and discharge from a hospital, nursing or convalescent home, hospice, long‑term care facility, or other health care facility.
D. Consenting to and authorizing my admission to and retention in a facility for the care or treatment of mental illness.
E. Consenting to and authorizing the administration of medications for mental health treatment and electroconvulsive treatment (ECT) commonly referred to as "shock treatment."
F. Giving consent for, withdrawing consent for, or withholding consent for, X‑ray, anesthesia, medication, surgery, and all other diagnostic and treatment procedures ordered by or under the authorization of a licensed physician, dentist, podiatrist, or other health care provider. This authorization specifically includes the power to consent to measures for relief of pain.
G. Authorizing the withholding or withdrawal of life‑prolonging measures.
H. Providing my medical information at the request of any individual acting as my attorney‑in‑fact under a durable power of attorney or as a Trustee or successor Trustee under any Trust Agreement of which I am a Grantor or Trustee, or at the request of any other individual whom my health care agent believes should have such information. I desire that such information be provided whenever it would expedite the prompt and proper handling of my affairs or the affairs of any person or entity for which I have some responsibility. In addition, I authorize my health care agent to take any and all legal steps necessary to ensure compliance with my instructions providing access to my protected health information. Such steps shall include resorting to any and all legal procedures in and out of courts as may be necessary to enforce my rights under the law and shall include attempting to recover attorneys' fees against anyone who does not comply with this health care power of attorney.
I. To the extent I have not already made valid and enforceable arrangements during my lifetime that have not been revoked, exercising any right I may have to authorize an autopsy or direct the disposition of my remains.
J. Taking any lawful actions that may be necessary to carry out these decisions, including, but not limited to: (i) signing, executing, delivering, and acknowledging any agreement, release, authorization, or other document that may be necessary, desirable, convenient, or proper in order to exercise and carry out any of these powers; (ii) granting releases of liability to medical providers or others; and (iii) incurring reasonable costs on my behalf related to exercising these powers, provided that this health care power of attorney shall not give my health care agent general authority over my property or financial affairs.
5. Special Provisions and Limitations.
(Notice: The authority granted in this document is intended to be as broad as possible so that your health care agent will have authority to make any decisions you could make to obtain or terminate any type of health care treatment or service. If you wish to limit the scope of your health care agent's powers, you may do so in this section. If none of the following are initialed, there will be no special limitations on your agent's authority.)
A. Limitations about Artificial Nutrition or Hydration: In exercising the authority to make health care decisions on my behalf, my health care agent:
______________ shall NOT have the authority to
withhold artificial nutrition
(Initial) (such as through tubes) OR may
exercise that authority only
in accordance with the following
special provisions:
__________________________________________________
__________________________________________________
______________ shall NOT have the authority to
withhold artificial hydration
(Initial) (such as through tubes) OR may
exercise that authority only
in accordance with the following
special provisions:
__________________________________________________
__________________________________________________
NOTE: If you initial either block but do not insert any special provisions, your health care agent shall have NO AUTHORITY to withhold artificial nutrition or hydration.
______________ B. Limitations Concerning Health Care
Decisions. In exercising
(Initial) the authority to make health
care decisions on my behalf, the
authority of my health care agent
is subject to the following
special provisions: (Here you may
include any specific
provisions you deem appropriate
such as: your own definition
of when life‑prolonging
measures should be withheld or
discontinued, or instructions to
refuse any specific types of
treatment that are inconsistent
with your religious beliefs, or
are unacceptable to you for any
other reason.)
__________________________________________________
__________________________________________________
NOTE: DO NOT initial unless you insert a limitation.
______________ C. Limitations Concerning Mental
Health Decisions. In
(Initial) exercising the authority to
make mental health decisions on
my behalf, the authority of my
health care agent is subject to
the following special provisions:
(Here you may include any
specific provisions you deem
appropriate such as: limiting
the grant of authority to make
only mental health treatment
decisions, your own instructions
regarding the administration
or withholding of psychotropic
medications and
electroconvulsive treatment (ECT),
instructions regarding
your admission to and retention in
a health care facility for
mental health treatment, or
instructions to refuse any specific
types of treatment that are
unacceptable to you.)
__________________________________________________
__________________________________________________
NOTE: DO NOT initial unless you insert a limitation.
______________ D. Advance Instruction for Mental
Health Treatment. (Notice:
(Initial) This health care power of
attorney may incorporate or be
combined with an advance
instruction for mental health
treatment, executed in accordance
with Part 2 of Article 3 of
Chapter 122C of the General
Statutes, which you may use to
state your instructions regarding
mental health treatment in
the event you lack capacity to
make or communicate mental
health treatment decisions.
Because your health care agent's
decisions must be consistent with
any statements you have
expressed in an advance
instruction, you should indicate here
whether you have executed an
advance instruction for mental
health treatment):
__________________________________________________
__________________________________________________
NOTE: DO NOT initial unless you insert a limitation.
______________ E. Autopsy and Disposition of
Remains. In exercising the
(Initial) authority to make decisions
regarding autopsy and disposition
of remains on my behalf, the
authority of my health care agent
is subject to the following special
provisions and limitations.
(Here you may include any specific
limitations you deem
appropriate such as: limiting the
grant of authority and the
scope of authority, or
instructions regarding burial or
cremation):
__________________________________________________
__________________________________________________
NOTE: DO NOT initial unless you insert a limitation.
6. Organ Donation.
To the extent I have not already made valid and enforceable arrangements during my lifetime that have not been revoked, my health care agent may exercise any right I may have to:
______________ donate any needed organs or parts; or
(Initial)
______________ donate only the following organs or parts:
(Initial)
__________________________________________________
NOTE: DO NOT INITIAL BOTH BLOCKS ABOVE.
______________ donate my body for anatomical study if needed.
(Initial)
______________ In exercising the authority to
make donations, my health care
(Initial) agent is subject to the
following special provisions and
limitations: (Here you may include
any specific limitations
you deem appropriate such as:
limiting the grant of authority
and the scope of authority, or
instructions regarding gifts of
the body or body parts.)
__________________________________________________
__________________________________________________
__________________________________________________
NOTE: DO NOT initial unless you insert a limitation.
NOTE: NO AUTHORITY FOR ORGAN DONATION IS GRANTED IN THIS INSTRUMENT WITHOUT YOUR INITIALS.
7. Guardianship Provision.
If it becomes necessary for a court to appoint a guardian of my person, I nominate the persons designated in Section 1, in the order named, to be the guardian of my person, to serve without bond or security. The guardian shall act consistently with G.S. 35A‑1201(a)(5).
8. Reliance of Third Parties on Health Care Agent.
A. No person who relies in good faith upon the authority of or any representations by my health care agent shall be liable to me, my estate, my heirs, successors, assigns, or personal representatives, for actions or omissions in reliance on that authority or those representations.
B. The powers conferred on my health care agent by this document may be exercised by my health care agent alone, and my health care agent's signature or action taken under the authority granted in this document may be accepted by persons as fully authorized by me and with the same force and effect as if I were personally present, competent, and acting on my own behalf. All acts performed in good faith by my health care agent pursuant to this power of attorney are done with my consent and shall have the same validity and effect as if I were present and exercised the powers myself, and shall inure to the benefit of and bind me, my estate, my heirs, successors, assigns, and personal representatives. The authority of my health care agent pursuant to this power of attorney shall be superior to and binding upon my family, relatives, friends, and others.
9. Miscellaneous Provisions.
A. Revocation of Prior Powers of Attorney. I revoke any prior health care power of attorney. The preceding sentence is not intended to revoke any general powers of attorney, some of the provisions of which may relate to health care; however, this power of attorney shall take precedence over any health care provisions in any valid general power of attorney I have not revoked.
B. Jurisdiction, Severability, and Durability. This Health Care Power of Attorney is intended to be valid in any jurisdiction in which it is presented. The powers delegated under this power of attorney are severable, so that the invalidity of one or more powers shall not affect any others. This power of attorney shall not be affected or revoked by my incapacity or mental incompetence.
C. Health Care Agent Not Liable. My health care agent and my health care agent's estate, heirs, successors, and assigns are hereby released and forever discharged by me, my estate, my heirs, successors, assigns, and personal representatives from all liability and from all claims or demands of all kinds arising out of my health care agent's acts or omissions, except for my health care agent's willful misconduct or gross negligence.
D. No Civil or Criminal Liability. No act or omission of my health care agent, or of any other person, entity, institution, or facility acting in good faith in reliance on the authority of my health care agent pursuant to this Health Care Power of Attorney shall be considered suicide, nor the cause of my death for any civil or criminal purposes, nor shall it be considered unprofessional conduct or as lack of professional competence. Any person, entity, institution, or facility against whom criminal or civil liability is asserted because of conduct authorized by this Health Care Power of Attorney may interpose this document as a defense.
E. Reimbursement. My health care agent shall be entitled to reimbursement for all reasonable expenses incurred as a result of carrying out any provision of this directive.
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.
This the _____ day of ______________, 20____.
________________________(SEAL)
10. Signature.
Signature must be witnessed by two qualified witnesses or proved by a notary public. Please complete Section A or Section B, below.
A. Witnesses
I hereby state that the principal, _______________, being of sound mind, signed (or directed another to sign on the principal's behalf) 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 a licensed health care provider or mental health treatment provider who is (1) an employee of the principal's attending physician or mental health treatment provider, (2) an employee of the health facility in which the principal is a patient, or (3) an employee of a nursing home or any adult care home where the principal resides. I further state that I do not have any claim against the principal or the estate of the principal.
Date: _____________________________ Witness: ___________________________
Date: _____________________________ Witness: ___________________________
________________COUNTY, _________________STATE
Sworn to (or affirmed) and subscribed before meSubscribed
this day by _____________________
(type/print name of signer)
______________________
(type/print name of witness)
______________________
(type/print name of witness)
B. Notarization
Date: ___________________________ ______________________________
(Official Seal) Signature of Notary Public
__________________, Notary Public
Printed or typed name
My commission expires: __________"
SECTION 3. G.S. 90‑321(c) reads as rewritten:
"(c) The attending physician shall follow, subject to subsections (b), (e), and (k) of this section, a declaration:
(1) That expresses a desire of the declarant that life‑prolonging measures not be used to prolong the declarant's life if, as specified in the declaration as to any or all of the following:
a. The declarant has an incurable or irreversible condition that will result in the declarant's death within a relatively short period of time; or
b. The declarant becomes unconscious and, to a high degree of medical certainty, will never regain consciousness; or
c. The declarant suffers from advanced dementia or any other condition resulting in the substantial loss of cognitive ability and that loss, to a high degree of medical certainty, is not reversible.
(2) That states that the declarant is aware that the declaration authorizes a physician to withhold or discontinue the life‑prolonging measures; and
(3) That has been signed by the meets either
of the following requirements:
a. Has been signed by the declarant in
the presence of two witnesses who believe the declarant to be of sound mind and
who state that they (i) are not related within the third degree to the
declarant or to the declarant's spouse, (ii) do not know or have a reasonable
expectation that they would be entitled to any portion of the estate of the
declarant upon the declarant's death under any will of the declarant or codicil
thereto then existing or under the Intestate Succession Act as it then
provides, (iii) are not the attending physician, licensed health care providers
who are paid employees of the attending physician, paid employees of a health
facility in which the declarant is a patient, or paid employees of a nursing
home or any adult care home in which the declarant resides, and (iv) do not
have a claim against any portion of the estate of the declarant at the time of
the declaration; anddeclaration.
b. Has been proved before a clerk or assistant clerk of superior court, or a notary public who certifies substantially as set out in subsection (d1) of this section. A notary who takes the acknowledgement may but is not required to be a paid employee of the attending physician, a paid employee of a health facility in which the declarant is a patient, or a paid employee of a nursing home or any adult care home in which the declarant resides.
(4) That has been proved before a clerk or
assistant clerk of superior court, or a notary public who certifies substantially
as set out in subsection (d1) of this section. A notary who takes the
acknowledgement may but is not required to be a paid employee of the attending
physician, a paid employee of a health facility in which the declarant is a
patient, or a paid employee of a nursing home or any adult care home in which
the declarant resides."
SECTION 4. G.S. 90‑321(d1) reads as rewritten:
"(d1) The following form is specifically determined to meet the requirements of subsection (c) of this section:
ADVANCE DIRECTIVE FOR A NATURAL DEATH ("LIVING WILL")
NOTE: YOU SHOULD USE THIS DOCUMENT TO GIVE YOUR HEALTH CARE PROVIDERS INSTRUCTIONS TO WITHHOLD OR WITHDRAW LIFE‑PROLONGING MEASURES IN CERTAIN SITUATIONS. THERE IS NO LEGAL REQUIREMENT THAT ANYONE EXECUTE A LIVING WILL.
GENERAL INSTRUCTIONS: You can use this Advance Directive ("Living Will") form to give instructions for the future if you want your health care providers to withhold or withdraw life‑prolonging measures in certain situations. You should talk to your doctor about what these terms mean. The Living Will states what choices you would have made for yourself if you were able to communicate. Talk to your family members, friends, and others you trust about your choices. Also, it is a good idea to talk with professionals such as your doctors, clergypersons, and lawyers before you complete and sign this Living Will.
You do not have to use this form to give those instructions, but if you create your own Advance Directive you need to be very careful to ensure that it is consistent with North Carolina law.
This Living Will form is intended to be valid in any jurisdiction in which it is presented, but places outside North Carolina may impose requirements that this form does not meet.
If you want to use this form,
you must complete it, sign it, and have your signature witnessed by two
qualified witnesses and or proved by a notary public. Follow the
instructions about which choices you can initial very carefully. Do not sign
this form until two witnesses and or a notary public are
present to watch you sign it. You then should consider giving a copy to your
primary physician and/or a trusted relative, and should consider filing it with
the Advanced Health Care Directive Registry maintained by the North Carolina
Secretary of State: http://www.nclifelinks.org/ahcdr/
My Desire for a Natural Death
I, ____________________, being of sound mind, desire that, as specified below, my life not be prolonged by life‑prolonging measures:
1. When My Directives Apply
My directions about prolonging my life shall apply IF my attending physician determines that I lack capacity to make or communicate health care decisions and:
NOTE: YOU MAY INITIAL ANY AND ALL OF THESE CHOICES.
_________ I have an
incurable or irreversible condition that will result
(Initial) in my death within a relatively
short period of time.
_________ I become
unconscious and my health care providers
(Initial) determine that, to a high degree of
medical certainty, I will
never regain my consciousness.
_________ I suffer
from advanced dementia or any other condition
(Initial) which results in the substantial
loss of my cognitive ability
and my health care providers determine
that, to a high
degree of medical certainty, this loss
is not reversible.
2. These are My Directives about Prolonging My Life:
In those situations I have initialed in Section 1, I direct that my health care providers:
NOTE: INITIAL ONLY IN ONE PLACE.
_________ may withhold or withdraw life‑prolonging measures.
(Initial)
_________ shall withhold or withdraw life‑prolonging measures.
(Initial)
3. Exceptions – "Artificial Nutrition or Hydration"
NOTE: INITIAL ONLY IF YOU WANT TO MAKE EXCEPTIONS TO YOUR INSTRUCTIONS IN PARAGRAPH 2.
EVEN THOUGH I do not want my life prolonged in those situations I have initialed in Section 1:
_________ I DO
want to receive BOTH artificial hydration AND
(Initial) artificial nutrition (for example,
through tubes) in those
situations.
NOTE: DO NOT INITIAL THIS BLOCK IF ONE OF THE BLOCKS BELOW IS INITIALED.
_________ I DO
want to receive ONLY artificial hydration (for
(Initial) example, through tubes) in those
situations.
NOTE: DO NOT INITIAL THE BLOCK ABOVE OR BELOW IF THIS BLOCK IS INITIALED.
_________ I DO
want to receive ONLY artificial nutrition (for
(Initial) example, through tubes) in those
situations.
NOTE: DO NOT INITIAL EITHER OF THE TWO BLOCKS ABOVE IF THIS BLOCK IS INITIALED.
4. I Wish to be Made as Comfortable as Possible
I direct that my health care providers take reasonable steps to keep me as clean, comfortable, and free of pain as possible so that my dignity is maintained, even though this care may hasten my death.
5. I Understand my Advance Directive
I am aware and understand that this document directs certain life‑prolonging measures to be withheld or discontinued in accordance with my advance instructions.
6. If I have an Available Health Care Agent
If I have appointed a health care agent by executing a health care power of attorney or similar instrument, and that health care agent is acting and available and gives instructions that differ from this Advance Directive, then I direct that:
_________ Follow
Advance Directive: This Advance Directive will
(Initial) override instructions my
health care agent gives about
prolonging my life.
_________ Follow
Health Care Agent: My health care agent has
(Initial) authority to override this
Advance Directive.
NOTE: DO NOT INITIAL BOTH BLOCKS. IF YOU DO NOT INITIAL EITHER BOX, THEN YOUR HEALTH CARE PROVIDERS WILL FOLLOW THIS ADVANCE DIRECTIVE AND IGNORE THE INSTRUCTIONS OF YOUR HEALTH CARE AGENT ABOUT PROLONGING YOUR LIFE.
7. My Health Care Providers May Rely on this Directive
My health care providers shall not be liable to me or to my family, my estate, my heirs, or my personal representative for following the instructions I give in this instrument. Following my directions shall not be considered suicide, or the cause of my death, or malpractice or unprofessional conduct. If I have revoked this instrument but my health care providers do not know that I have done so, and they follow the instructions in this instrument in good faith, they shall be entitled to the same protections to which they would have been entitled if the instrument had not been revoked.
8. I Want this Directive to be Effective Anywhere
I intend that this Advance Directive be followed by any health care provider in any place.
9. I have the Right to Revoke this Advance Directive
I understand that at any time I may revoke this Advance Directive in a writing I sign or by communicating in any clear and consistent manner my intent to revoke it to my attending physician. I understand that if I revoke this instrument I should try to destroy all copies of it.
This the ________ day of ____________, _________.
___________________________________
Print Name __________________________
10. Signature.
Signature must be witnessed by two qualified witnesses or proved by a notary public. Please complete Section A or Section B, below.
A. Witnesses
I hereby state that the declarant, ______________________, being of sound mind, signed (or directed another to sign on declarant's behalf) the foregoing Advance Directive for a Natural Death in my presence, and that I am not related to the declarant by blood or marriage, and I would not be entitled to any portion of the estate of the declarant under any existing will or codicil of the declarant or as an heir under the Intestate Succession Act, if the declarant died on this date without a will. I also state that I am not the declarant's attending physician, nor a licensed health care provider who is (1) an employee of the declarant's attending physician, (2) nor an employee of the health facility in which the declarant is a patient, or (3) an employee of a nursing home or any adult care home where the declarant resides. I further state that I do not have any claim against the declarant or the estate of the declarant.
Date: _____________________________ Witness: ___________________________
Date: _____________________________ Witness: ___________________________
________________COUNTY, _________________STATE
Sworn to (or affirmed) and subscribed before me Subscribed
this day by _____________________
(type/print name of declarant)
________________________
(type/print name of witness)
________________________
(type/print name of witness)
B. Notarization
Date ___________________________ ______________________________
(Official Seal) Signature of Notary Public
__________________, Notary Public
Printed or typed name
My commission expires: _________"
SECTION 5. This act becomes effective October 1, 2015.